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Full text of "U.S. Navy Medicine Volume 68, Number 2 February 1977"

*, 

February 19>7 M 








VADM WUlard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufman, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Con tributing Editor-in - Chief: 
CDR C.T. Cloutier (MC) 

Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MC); Fleet Support: CAPT R,W. Jones 
(MC); Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Daltoti (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC): Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPTH.E. Glick(MC) 



POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Medical De- 
partment officers of the Regular Navy and Naval Reserve 
official and professional information relative to medicine, 
dentistry, and the allied health sciences. Opinions 
expressed are those of the authors and do not necessarily 
represent the official position of the Department of the 
Navy, the Bureau of Medicine and Surgery, or any other 
governmental department or agency. Trade names are used 
for identification only and do not represent an endorsement 
by the Department of the Navy or the Bureau of Medicine 
and Surgery. Although U.S. Navy Medicine may cite or 
extract from directives, official authority for action should 
be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department officers via the Standard 
Navy Distribution List. Requests to increase or decrease the 
number of allotted copies should be forwarded to U.S. Navy 
Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine. Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C 20372. Telephone: (Area Code 202) 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and wilt 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P 35). 



NAVMED P-50S8 



U.S.NAVY 




Volume 68, Number 2 
February 1977 



1 From the Surgeon General 

2 Department Rounds 

Awards, advances highlight professional meetings 
officer learns to walk again at NRMC Oakland 



A Greek 



Special Report 

The Surgeon General's Eighth Annual Specialties Advisory 
Conference and Committees' Meeting 

6 The Director of Clinical Services Committee 
CAPT D.C. Good, MC, USN 

7 Internal Medicine Committee 
CAPT D.O. Caste/I, MC, USN 

8 Utilization of Family Practice 
CDR R.W. Higg/ns, MC, USNR 

9 Preservation of Identity of Operating Specialists 
CAPT F.E. Dully, Jr., MC, USN 

1 1 Adaptation of the Internship to Fit Navy Requirements 
CAPT D.R. Cord ray, MC, USN 

11 The Essential Continuum of the Pediatric Residency 
CAPT D.W. Bailey, MC, USN 

12 Audiometry Screening 

CAPT T.F. Miller, Jr., MC, USN 

13 On the Necessity for Computerized Tomography in Naval Hospitals 
CAPTC.B. Early, MC, USN 

15 Oral Surgeons Committee 

CAPT T.W. McKean, DC, USN 

15 Radical Approach to Health Care Delivery 
CAPT H.J. Sears, MC, USN 

16 Manpower Requirements in Highly Specialized Services 
CAPT C. F. Bishop, MC, USN 

18 Discussion 

23 BUMED SITREP 

24 Clinical Notes 

Medical Support in Antarctica During Operation Deep Freeze 
LCDR D.B. Moyer, MC, USNR 

26 Independent Duty 

The Influence of High-Risk Groups on the Incidence of Gonorrhea 
CDR L.J. Melton III, MC, USN 

28 Notes and Announcements 

Flight surgeon billets open . . . Financial and supply management 
training announced . . . Dental continuing education courses set , . . 
New rules to purchase firearms . . . New clinic opens at NAS Memphis 
. . . Revised instructions may affect retirement , . . Awards and 
honors . . . American Board certifications 

COVER: Members of Operation Deep Freeze climb a snowbank in Ant- 
arctica. LCDR D.B. Moyer, MC, USNR reports on medical support for 
this operation, beginning on page 24. 

This issue introduces a new section, "Independent Duty," which will fea- 
ture topics of special interest to independent duty corpsmen. In the first 
offering, CDR L.J. Melton III (MC) discusses the influence of high-risk 
groups on the incidence of gonorrhea, beginning on page 26. 



From the Surgeon General 



Senior Enlisted Personnel: 
Let's Make the Most of Them 



Austere funding demands that we 
make full use of all our resources. 
This is especially true of our person- 
nel resources, which account for a 
large part of the cost of the services 
we provide. 

One area which should be re- 
viewed is use of senior enlisted per- 
sonnel— E-7's, E-8's, and E-9's. 
This group is, for the most part, 
composed of men and women who 
have not only a high degree of tech- 
nical skill acquired through formal 
training, but also many years of ex- 
perience. They are invaluable 
leaders, counselors, and advisers of 
our junior personnel. 

Unfortunately, many senior en- 
listed members are not being as- 
signed where they can perform at 
their maximum potential. The re- 
sults of such "misutilization" are 
twofold: first, the command, the 
Medical Department, and the Navy 
suffer financially when someone is 
paid to do less than he or she can; 
second, many senior petty officers 
leave the Navy as soon as they have 
the minimum time they need to 
transfer to the Fleet Reserve. These 
men and women often cite "lack of 
job satisfaction" or "no challenge 
in the assignment" as big factors in 
their decision to leave. 

There are many billets to which 
assignment of senior enlisted per- 
sonnel would benefit both the com- 
mand and the individual; such bil- 
lets include: 

• staff personnel officer; 

• security officer; 




VADM Arentzen 

• assistant patient affairs officer; 

• administrative assistant to the 
director of administrative services, 
chiefs of service, department heads, 
and type commanders' staffs; 

• special services officer; 

• CHAMPUS adviser; 

• career counselor. 

While these are not the only bil- 
lets to which senior enlisted person- 
nel could be detailed, they repre- 
sent challenging positions which re- 
quire the individuals assigned to 
accept greater responsibility and 
demonstrate their ability. 

The size and mission of the com- 
mand will, to a large degree, dictate 



the seniority or pay grade of the 
man or woman who fills the billet. 
But every command has certain bil- 
lets ideally suited to the skills and 
experience of senior enlisted per- 
sonnel. Manpower authorizations 
should be reviewed and changes re- 
quested as required to implement a 
program that will use all the ability 
of these members; when necessary, 
provision should be made to train 
individuals to the needs of the job. If 
we give maximum support to this 
concept, we can demand maximum 
performance. 

In the skills and experience of 
these, our junior management per- 
sonnel, we have the potential to 
maintain and further improve the 
quality of our health care delivery 
system. We must provide our senior 
enlisted Medical Department mem- 
bers with broad experience which, 
combined with their mature leader- 
ship capability, will enable them to 
make greater contributions in our 
hospitals and operational billets. 



M 




W.P. Arentzen 

Vice Admiral, Medical Corps 

United States Navy 



Volume 68, February 1977 



Department Rounds 




Awards, Advances Highlight 
Professional Meetings 



Professional meetings — whether 
annual gatherings, conferences, 
seminars, short courses, or sympo- 
sia — help keep Medical Department 
members abreast of new develop- 
ments in their field. SECNAV In- 
struction 4651. 15C of 11 December 
1976 emphasizes that attendance at 
such meetings is an accepted part of 
professional career training and is 
the Navy's preferred method for 
providing refresher training and 
education. 

Three professional meetings im- 
portant to Medical Department 
members convened during the clos- 
ing months of 1976. At the 83rd an- 
nual meeting of the Association of 
Military Surgeons of the United 
States, three Navy medical officers 
and a Medical Service Corps officer 
were honored for their contributions 
to military medicine. Military peri- 
natal care and expanded roles for 
pediatric nurse practitioners were 
among the topics tackled by the Sec- 
tion on Military Pediatrics during 
the annual meeting of the American 
Academy of Pediatrics. And Navy 
efforts to provide safe working 
places on land and at sea were dis- 
cussed at the 19th Annual Occupa- 
tional Health Workshop. US Navy 
Medicine thanks all who contri- 
buted to the following reports: 

AMSUS. During the 83rd annual 
meeting of the Association of Mili- 
tary Surgeons of the United States 
(AMSUS), held in San Antonio 31 
Oct-4 Nov 1976, CAPT George M. 
Lawton (MC), deputy director of the 
Occupational and Preventive Medi- 
cine Division at the Bureau of Medi- 
cine and Surgery, received the 
Gorgas Medal for distinguished 
work in preventive medicine. Dr. 
Lawton was honored for his pioneer- 
ing efforts in developing and man- 
aging the Navywide occupational 



health program. His exceptional ac- 
complishments include developing 
occupational health training, re- 
search, and development programs; 
and major contributions to the pro- 
fessional literature. 

CDR Lee J. Melton III (MC), head 
of the Epidemiology Section, BU- 
MED, received the Donald H. 
Gaylor Award for outstanding con- 
tributions in the field of tuberculo- 
sis. CDR Melton revitalized the 
Navy's tuberculosis control pro- 
gram, securing contacts with other 
government agencies, consulting 
experts in the field, and writing an 
unusually clear implementing direc- 
tive (BUMED Instruction 6224.1D 
of 8 Aug 1975) to establish the Navy 
program. 

LCDR Robert Shaw, Jr. (MC) of 
Navy Environmental and Preventive 
Medicine Unit #6, Pearl Harbor, 
Hawaii, was awarded the Sir Henry 
S. Wellcome Medal and Prize for 
"Preventive Medicine in the Viet- 
namese Refugee Camps on Guam," 
judged the best essay on a subject 
relating to military medicine. 

CDR Barbara Munroe (MSC) won 
the Major Louis Livingston Seaman 




Honored by AMSUS: CAPT George 
M. Lawton (MC), above, receives 
Gorgas Medal; CDR Lee J. Melton 
III (MC), left, wins Gaylor Award. 

Prize, awarded for a notable article 
published in Military Medicine 
during the previous year. Her 
winning article, "Rehabilitation of 
the Upper Extremity Traumatic 
Amputee," co-authored by LCDR 
Richard J. Nasca (MSC), appeared 
in the June 1975 issue. Formerly 
chief of the Occupational Therapy 
Branch at Naval Regional Medical 
Center Philadelphia, CDR Munroe 
is now chief of that facility's Secu- 
rity Service. 

This year's meeting, featuring 
the theme "Spirit of Federal Medi- 
cal Support for 1976 — A Bicenten- 
nial Report," was presided over by 
AMSUS president, Air Force Sur- 
geon General LT GEN George E. 
Schafer. Malcolm C. Todd, M.D., 
immediate past president of the 
American Medical Association, de- 
livered the keynote address. 

MILITARY PEDIATRICS. The 
Section on Military Pediatrics pre- 
sented a scientific program of nine 
papers during the annual meeting 
of the American Academy of Pediat- 
rics, held 17-22 Oct 1976 in Chicago. 
CDR William McCurley (MC), chief 
of the Pediatrics Service at NRMC 



U.S. Navy Medicine 



Philadelphia, described how medi- 
cal, psychological, and educational 
specialists can use a team approach 
to help the learning-disabled child. 
CDR McCurley described a pro- 
gram, developed at the National 
Naval Medical Center, in which the 
pediatrician performs medical and 
neurological evaluations of the 
child, counsels the parents, and acts 
as the child's advocate in the 
schools; the pediatrician also works 
with other professionals — psycholo- 
gists, social workers, education di- 
agnosticians, and community guid- 
ance counselors — to evaluate the 
child and develop a therapeutic pro- 
gram. Pediatric residents and the 
children's parents responded posi- 
tively to this clinic experience. 

Another Navy pediatrician, LCDR 
John Wimmer (MC), called for uni- 
form standards of perinatal care in 
all military hospitals, and for inter- 
service cooperation to improve peri- 
natal health care delivery. After 
surveying the perinatal capabilities 
of military hospitals, LCDR Wim- 
mer found that 14 hospitals had 
enough perinatal services to be 
designated as regional referral cen- 
ters, able to provide complete care 
for high-risk mothers and infants; 
however, many of these 14 hospitals 
had inadequate anesthesiology and 
neonatal intensive nursing support. 
Fifty percent of smaller military 
hospitals, which should be able to 
provide routine perinatal care and 
screening for high-risk pregnancies 
and newborns, had significant defi- 
ciencies in laboratory and nursing 
services. LCDR Wimmer proposed 
tri- service cooperation and pooling 
of regional resources to improve 
military perinatal care. 

A study of the military aeromedi- 
cal evacuation system for transport- 
ing high-risk and ill infants to hos- 
pitals was reported by MAJ William 
J. Oetgen, MC, USA, and LT COL 
Richard D. Landes, MC, USA, of 
the Walter Reed Army Medical 
Center, Washington, D.C. Statistics 
derived from a review of aeromedi- 
cal evacuation admissions to that 
facility's intensive care nursery over 
50 months revealed that aeromedi- 



cally evacuated infants had a 19% 
mortality rate, compared to a 10% 
mortality rate for all intensive care 
nursery patients. Differences in 
diagnosis did not account for this 
greater mortality, but hazards of the 
aircraft environment, such as hypo- 
thermia (associated with a 43% 
mortality rate), are suspected, MAJ 
Oetgen and LT COL Landes noted. 
A tri-service study is planned of the 
aeromedical evacuation system. 

Psychosocial aspects of the un- 
wed teenage mother were discussed 
by MAJ Arthur Elster, MC, USA, of 
Madigan Army Medical Center, 
Tacoma, Wash., who suggested 
that unwed pregnant adolescents 
can be grouped into three catego- 
ries, based on their personality pro- 
files, their response to the pregnan- 
cy, and the pregnancy's effect on 
their psychosocial development. A 
well adjusted teenager who re- 
sponds positively to her pregnancy 
will need only routine medical care; 
but 20% of unwed teenage mothers 
have significant personality defi- 
ciencies, respond negatively to their 
pregnancy, and require psychiatric 
care. A third, "mixed" group — 
40% of unwed adolescent mothers 
— have mildly disturbed personali- 
ties but good potential for emotional 
growth. MAJ Elster said that 
unwed pregnant adolescents do well 
in direct proportion to the amount of 
professional attention, support at 
home, and instruction in raising 
children they receive. 

A primary care clinic for adoles- 
cents at Fitzsimons Army Medical 
Center, Denver, was described by 
MAJ Russell V. McDowell, USAF, 
MC, and LT COL Joe M. Sanders, 
Jr., MC, USA. This clinic has an 
"open door" policy: adolescents 
aged 12 to 19 years are permitted to 
seek primary care without parental 
permission or medical referral. The 
speakers stressed that, soon after 
secondary sexual development be- 
gins, adolescents should have a 
routine physical examination, to in- 
clude counseling on common ado- 
lescent problems. 

LT COL James H. Nelson, MC, 
USA, reported on a pediatric 



screening program run by Red 
Cross volunteers at Madigan Army 
Medical Center. The volunteers are 
selected and trained by the pediat- 
ric staff and are allowed to interview 
parents to obtain medical, social, 
and genetic histories; they also 
complete growth records, perform 
visual, auditory and blood pressure 
exams, check for scoliosis, organize 
medical records, check patients' im- 
munization status, and counsel 
parents. Using information ob- 
tained by these volunteers, a pedia- 
trician can completely evaluate a 
child during a 15-minute examina- 
tion. 




) 




CDR B. Munroe <MSC) 

Writes prize-winning article 

MAJ Jacolynn I. Murphy, USAF, 
NC, of USAF Medical Center, Scott 
Air Force Base, 111., identified 
several jobs that could be assigned 
to pediatric nurse practitioners: 
screening and managing minor, 
acute, and chronic illness; taking 
histories and performing physical 
assessments in specialty clinics; 
caring for well babies; performing 
screening procedures such as audi- 
ometric evaluation; and teaching 
parents how to care for children. 
CAPT Christina Addison, ANC, 
USA, of William Beaumont Army 
Medical Center, El Paso, Tex., de- 



Volume 68, February 1977 



scribed how she coordinated a hos- 
pitalization follow-up clinic run by 
pediatric nurse practitioners; this 
clinic improved continuity of care, 
instruction of parents, and patient- 
staff relationships. 

A pediatric nurse clinician can 
provide comprehensive care in the 
newborn nursery, said MAJ Marian 
Walls, ANC, USA, and CAPT 
Connie Shaw, ANC, USA, of Fitz- 
simons Army Medical Center. The 
nursery pediatric nurse practitioner 
can perform all physical examina- 
tions, direct nursery care of infants, 
complete laboratory evaluations for 
common problems such as hyper- 
bilirubinemia, and counsel mothers. 

The Military Pediatrics Section 
presented its second annual Out- 
standing Service Award to retired 
Navy pediatrician CAPT Andrew 
Margileth for his contributions to 
military pediatrics and his concern 
for the health and welfare of all 
children. A former chairman of 
pediatrics at the National Naval 
Medical Center, Dr. Margileth is 
now professor and assistant chair- 
man of pediatrics at George Wash- 
ington University School of Medi- 
cine, Washington, D.C. Two Navy 
pediatricians — CAPT Vernon Goller 
(MC) and CAPT Robert Biehl (MC) 
— were elected to the Section's 
eight-member executive committee. 
— CDR Leslie C. Ellwood (MC) 



OCCUPATIONAL HEALTH. More 
than 250 people attended the 19th 
Annual Occupational Health Work- 
shop sponsored by the Navy En- 
vironmental Health Center and held 
27 Sept-1 Oct 1976 in Charleston, 
S.C. The weekend before the work- 
shop, some 110 people attended 
refresher courses in federal work- 
ers' compensation, occupational 
lung disease and pulmonary func- 
tion testing, and industrial ventila- 
tion. 

In his opening address, Mr, 
George Marienthal, deputy assist- 
ant secretary of defense for environ- 
ment and safety, affirmed that 
"OSHA is here to stay," citing grim 
statistics to illustrate the need for 



Department of Defense compliance 
with the Occupational Safety and 
Health Act of 1970. The DOD record 
for 1975 was 1,500 deaths and 2,500 
disabling injuries attributed to oc- 
cupational hazards. The cost: $4.1 
billion. Mr. Marienthal reported 
that DOD has published two direc- 
tives (DOD Instructions 1000.11 and 
1000.18) on occupational safety and 
is giving high priority to completing 
the management information sys- 
tem. 

RADM J.D. Chase, assistant 
deputy chief of naval operations for 
logistics, said that the Navy's safety 
program often came from historical 



sponse to the DOD-directed pro- 
gram of compliance with OSHA, 
Admiral Chase listed several goals: 

• To institute a Navy occupational 
safety and health program which 
would not disturb operational safety 
programs already in effect. 

• To distinguish between programs 
for military and civilian employees 
of the Department of the Navy, and 
programs to protect civilians work- 
ing for the Navy under contract. 

• To inspect all Navy workplaces at 
least annually. 

• To train inspectors to identify oc- 
cupational hazards and prescribe 
solutions. 




^¥ 


i 


1 top** 


1 



Occupational health panel: (from left) J.S. Felton, M.D.; Mr. J. Schultz; Mr. P. 
Brodeur; Mr. R.C. Wands, director. Advisory Center on Toxicology, IMAS/NRC. 



concerns "written in blood." Noting 
the "perils of the sea" and the even 
greater perils that surround a war- 
ship, Admiral Chase said, "We 
have fires, some of them major, and 
we lose lives and incur injuries. We 
have collisions. We have explo- 
sions. We have accidents associated 
with moving machinery and equip- 
ment .... Every year we lose 
people by electrocution from im- 
properly grounded or improperly 
handled equipment. Every year we 
lose people by asphyxiation from 
entering nonventilated spaces with- 
out some form of breathing appara- 
tus." 

Admiral Chase praised the Naval 
Safety Center in Norfolk, Va., for 
the exacting safety precautions 
developed there to counter these 
hazards and other dangers associ- 
ated with nuclear weapons and 
nuclear propulsion. 

Response. Reviewing Navy re- 



• To improve health hazard data 
collecting methods. 

• To educate the fleet about occu- 
pational health hazards. 

• To work with unions representing 
civilian employees of the Navy. 

Admiral Chase said that elimi- 
nating occupational health hazards 
is as important to the Navy as pre- 
venting accidents. More research is 
needed to understand many occupa- 
tional health hazards, and programs 
must be designed to educate Navy 
people about these hazards. While 
calling for industrial hygienists at 
each region to assist in annual in- 
spections of the workplace, Admiral 
Chase cautioned that money and 
billets are hard to get. "If you think 
it's going to be easy, you are 
wrong," he told the group. 

RADM R.C. Laning (MC), assist- 
ant chief for operational medical 
support at the Bureau of Medicine 
and Surgery, said the Medical De- 



U.S. Navy Medicine 



partment has the organization and 
know-how to implement an effective 
occupational health program in the 
Navy, and reported that more re- 
sources may result from DOD and 
OPNAV action. He stressed the 
need to use to the fullest the few 
available resources. "We know that 
occupational health programs are 
good for the Navy and the Navy's 
people," Admiral Laning said. "No 
weapons system, no transportation 
system, no logistics system, no any 
system is complete without people 
to man them. And that's our job: to 
make sure those people are healthy 
and alert at their duty stations. To 
take every precaution to ensure that 
their working or living environment 
doesn't endanger them." 

Conference participants spent 
three days examining those aspects 
of the job and environment that 
represent the major hazard to 
health in the Navy. Problems con- 
sidered critical included chemical 
hazards, noise stress, ventilation, 
skin diseases, laboratory analysis, 
lung diseases, heat stress, pesti- 
cides, respirators, and radiation. 

Discussing medical support to the 
fleet, RADM K.H. Geib (MC), fleet 
surgeon and assistant chief of staff 
for medicine, Commander in Chief, 
Atlantic Fleet, said the "health and 
welfare of personnel is para- 
mount .... Sophisticated weapons 
systems are totally dependent on 
personnel." Admiral Geib sug- 
gested that hearing protection, heat 
stress, and sewage control should 
be given priority when services are 
provided to the fleet. 

The closing session was addressed 
by Mr. Paul Brodeur of the New 
Yorker, who delivered a blistering 
attack against the "industrial medi- 
cal complex . . . dedicated to the 
suppression of truth concerning 
health hazards" at the worksite. 
Mr. Brodeur warned that a society 
which will not protect itself against 
the catastrophic effects of poisoning 
may not be willing to protect itself 
against any other danger. 

— Mr. Kenneth Hed, consultant to the 
Navy Surgeon General for occupational 
health training. 



NRMC Oakland 

To Walk Again 

In January 1976, MAJ Nikolaos 
Skyvalos, Greek Army officer, was 
on duty with a NATO border patrol, 
policing the border that separates 
Greece from Albania, Yugoslavia, 
and Bulgaria. When an advance 
scout announced there were suspi- 
cious movements around the next 
hill, MAJ Skyvalos went to investi- 
gate. A sniper's bullet rang out, 
hitting him in the lower abdomen. 
As he fell, he activated a land mine 
— and the resulting explosion man- 
gled his legs. 

MAJ Skyvalos spent the next 
three months in a Greek hospital 
recovering from his injuries and re- 
gaining his strength. Then came the 
challenge of learning to walk again. 
Through the help of NATO, a Euro- 
pean prosthetic technician was sent 
to Fit him with new legs. It was 
hopeless — the artificial legs were 
too cumbersome and painful. MAJ 
Skyvalos became acutely de- 
pressed, and began to believe that 
he would never walk again. 

When told the Greek Government 
would pay his travel and hospitali- 
zation expenses in any NATO 
country to have another set of artifi- 
cial legs made, MAJ Skyvalos chose 
the United States — specifically, the 
Naval Prosthetics Research Labora- 
tory at Naval Regional Medical 
Center Oakland. He and his wife 
arrived at the medical center on 18 
Oct 1976. Assistant chief nurse CDR 
C. Marion Belezos and Kathy 
Taylor of the decedent affairs office 
took on the job of interpreting for 
the patient, who, it turned out, 
knew their relatives in Greece. 

What happened next is best 
expressed by the patient himself, in 
his letter to the medical center com- 
manding officer, RADM Henry A. 
Sparks (MC): 

Most respectfully, Admiral Sparks, 
allow me to say the dream of walking 
again is a reality, and more wonderful 
than it was imagined. Everyone in the 
hospital, civilian and military, has 




MAJ Nikolaos Skyvalos 

"My thanks will be eternal" 

treated me as a brother. I shall forever 
cherish the understanding, kindness, 
helpfulness and love, and above all the 
determination to keep me from being 
depressed and giving up. 

There are not words in any language 
that will express how I feel about every- 
thing that has been done and is being 
done for me. I know that it was God's 
will that brought me here, and my 
thanks will be eternal. 

With the final fitting of my legs, I 
walk without assistance. 1 am a com- 
plete man; a normal person on two legs 
with my faith restored. This I owe to 
your staff. 

Another thing that has contributed to 
my happiness is the reassurance of the 
friendship of the people of this great 
America for my country. 

Admiral, your entire staff, civilian 
and military, are superior individuals 
with wonderful hearts and souls de- 
voted to the handicapped. The world 
must know about this, and will. When I 
leave here, half of me will always 
remain in America. Half my body and 
half my soul belongs to the American 
people. I have a dedicated responsibility 
to inform my superiors and the people 
of Greece how wonderful the Americans 
are, and of their dedication to help 
others. 

I will never forget, as long as I may 
live, what you have done for me. May 
God protect this great country and her 
people. 

With my sincerest respect, 

Nikolaos Skyvalos 

An Officer of the Greek Army 



Volume 68, February 1977 



Special Report 



The Surgeon General's 8th Annual Specialties 
Advisory Conference and Committees' Meeting 

Accountability in Graduate Medical Education 



THIRD PLENARY SESSION 
24 September 1976 



The Director of Clinical 
Services Committee 



CAPT D.C. Good, MC, USN 
Director of Clinical Services 
Naval Regional Medical Center 
Portsmouth, Va. 

This morning we will learn the results of the various 
SAC 8 committees' deliberations. Each issue will be 
discussed for up to ten minutes. After the last presenta- 
tion there will be a question and answer period. 

There will be time to discuss only a few of the most 
important issues considered by the committees. I 
certainly don't want you to think that these few issues 
are the only problems we face. 

The first presentation is from the DCS (Director of 
Clinical Services) Committee. The director of clinical 
services is the assistant to the commanding officer, and 
succeeds to command in the CO's absence. The DCS is 
the purveyor of health care for his medical region, for 
certain fleet units, and occasionally for the Fleet 
Marine Force. Because his responsibilities include 
clinic care, education, and quality control for accredita- 
tion, the attention of the DCS is necessarily spread thin. 
The DCS Committee therefore recommended that the 
position of director of medical education be perma- 
nently established at Navy regional medical centers to 
coordinate the education programs. 



This account of SAC 8 is an edited (sometimes paraphrased or ab- 
breviated) version of the remarks and presentations of specified indi- 
viduals. Their comments do not necessarily reflect official views of 
the Navy Department or the naval service at large. 

SAC 8 was held 21-24 Sept 1976. The first plenary session and the 
Navy Surgeon General's address at the second plenary session were 
reported in th~ January 1977 issue of U.S. Navy Medicine. 



A second issue discussed in the DCS Committee was 
indoctrination into operational medicine, and manage- 
ment of that specialty. Staff medical officers receive 
operational medicine indoctrination through surgical 
teams, surgical support teams, ship's pools and Marine 
augment units. Many of the last group of newly com- 
missioned medical officers had previous service either 
with the fleet or as clinical clerks; few were receiving 
their first exposure to the Navy. These experienced 
officers did not really need a two-week indoctrination 
course; any needed indoctrination could just as well 
have been provided at their first duty station. 

If an Operational Medicine Service were established 
at naval regional medical centers, surface, air, sub- 
marine and Marine specialties could be integrated into 
a single functional unit and become the nucleus for in- 
doctrination, continuing operational education, and 
management of newly commissioned medical officers 
into a force ready for deployment during any opera- 
tional contingency. We therefore recommend discon- 
tinuation of the two-week indoctrination course previ- 
ously experienced medical officers now undergo before 
reporting to Navy regional medical centers; instead, 
these officers should be indoctrinated at their medical 
center as needed. 

The single-manager pool has been a great means to 
educate and reeducate medical officers to shipboard 
living conditions and limitations. In their three months 
aboard ship, they learn to appreciate the problems of 
being at sea. Medical officers have not always been 
overjoyed by the idea of spending three months away 
from their specialty, but they have been willing to 
deploy for up to 90 days because such deployment 
would improve their management of active-duty pa- 
tients. Upon their return, their comments were often 
favorable; they had learned much, but were glad to go 
back to their clinical practice. If single-manager pool 
deployments were to be extended to six or eight 
months, medical officer acceptance of the pool would 
change. It is therefore recommended that single- 
manager pool deployments continue to be limited to 90 
days. 



U.S. Navy Medicine 



During this period of austerity each command has 
considered reductions. Vertical cuts of medical services 
would reduce expenditures, but for savings to be sub- 
stantial and timely the cuts would have to be made in 
services that treat large numbers of civilians: the elimi- 
nation or drastic reduction of obstetrical services, for 
example. But much of the savings would be countered 
by an increase in operation and maintenance expendi- 
tures for outservice care of the pregnant active-duty 
woman. Closing a branch clinic possibly could reduce 
civilian employment and facility maintenance, but it 
would have considerable negative political impact and 
would greatly reduce morale. A vertical cut to eliminate 
care to a certain category of recipients, such as retired 
personnel or dependents, would seriously impair 
medical education, which depends so heavily on these 
patients to provide comprehensive medical experience. 
Vertical cuts of these patient categories would sound 
the death knell for Navy graduate medical education 
and for Navy medicine as we know it today. Navy 
medical practice would be less attractive and the Navy 
would certainly have less opportunity to recruit and re- 
tain physicians for its Medical Corps. We therefore 
recommend that vertical cuts in medical care not be 
implemented, except as a last resort. 



Internal Medicine Committee 



CAPT D.O. Castell, MC, USN 
Chief, Internal Medicine Service 
National Naval Medical Center 
Bethesda, Md. 

When you assemble a number of men to have the 
advantage of their joint wisdom, you inevitably assemble with 
these men all their prejudices, their passions, their areas of 
opinions, their local interests, and their selfish desires. From 
such an assembly can a perfect production be expected? 

This statement was made by Ben Franklin to describe 
the authors of the Constitution of the United States. 
The combined assembly of the chiefs of medicine and 
medicine subspecialties must certainly be guilty of 
many of these indictments. Despite our deficiencies, we 
have prepared a statement relating to a crucial issue 
facing Navy medicine: the definition of an internist in 
1976, and the relation of the internist to the family 
practitioner and the proposed operational medicine 
specialist in view of the recently defined mission of the 
Navy Medical Corps. 

Defining the internist and clarifying his position in 
medicine today is a complex problem requiring clear 
identification of the roles of many other medical spe- 
cialists. In the civilian community it has been suggested 
that the internist is one of that group of individuals who 
will provide primary patient care — a group that should 



include the family practitioner and the pediatrician, 
with some experts suggesting that obstetricians also be 
numbered among primary physicians. 

In military medicine the problem of defining the role 
of the internist is compounded by the recent OPNAV 
clarification of the Navy Medical Department mission 
which indicates that dependent care, and therefore the 
treatment of families, may have decreasing scope in the 
practice of medicine with the Navy. 

Another complication is the proposal that we now 
define yet another form of specialist — the operational 
medicine specialist — who would be more attuned to the 
unique needs of military medicine. Further magnifying 
the dilemma is the need to clarify the role of internal 
medicine subspecialists, and their relation to our pa- 
tients. 

Let us look at each of these problems in some detail. 
We all agree that the internist must play a major role in 
the primary care of patients. This has become a neces- 
sity not only in the Navy because of the decreasing 
numbers of general medical officers, but also through- 
out the civilian medical community. As a result, the 
American Board of Internal Medicine has decided that 
training in ambulatory patient care must become a 
crucial component of internal medicine training pro- 
grams in the U.S. Obviously, one of our problems is to 
define just how far-reaching these ambulatory care re- 
sponsibilities should be, and how the internist should 
relate to the other primary care physicians I mentioned 
earlier. 

We senior Navy internists are concerned over the 
marked escalation in the number of family practice 
physicians and family practice training programs in the 
Medical Department. Although there is no question 
that many families who qualify as military dependents 
and dependents of retired personnel definitely need 
and deserve medical care, these patients are clearly not 
included in the primary mission of the Navy Medical 
Department, which is to provide medical support for 
active-duty personnel. It therefore seems somewhat 
paradoxical for us to emphasize training family practi- 
tioners at a time when we are agonizing over ways to 
provide operational support. Training billets being con- 
verted into family practice programs may possibly be 
used more properly to augment internal medicine train- 
ing. We suggest that serious consideration be given to 
rethinking the need for and wisdom of continued esca- 
lation in family practice training in the Navy. 

An equally important consideration relates to the re- 
quirements for fleet support. We are presently sending 
fully trained internists and subspecialists in internal 
medicine to operational duty aboard ship. Would it not 
be equally difficult to justify sending a family practi- 
tioner to sea duty? And wouldn't such a practice gener- 
ate greater problems for us in terms of morale? 

Let us now consider the proposed new specialty of 
operational medicine. Admittedly, we must approach 
any discussion of this topic with considerable naivete; 



Volume 68, February 1977 



since none of us has "been there before," we know 
little about the long-term specifics of such a training 
program. However, we do have a gut reaction that more 
appropriate measures might be found to ensure 
operational support capability. We propose, for exam- 
ple: 

• institution of operational training during the gradu- 
ate level one year at Navy training hospitals; 

• careful scrutiny of the already established curricula 
of Navy flight surgeon and submarine training pro- 
grams to ensure modern capability for operational sup- 
port in these areas. 

At a time of decreasing resources, with each training 
billet becoming a precious commodity, it would seem 
that the last thing we need is another specialty. We 
suggest that operational needs could best be satisfied 
through improved general training of our GME-1 
trainees, and assignment of these physicians to a tour 
of operational duty following their GME-1 training. 
These individuals would form an effective cadre of 
career-oriented physicians ready to meet the Navy's 
needs for operational medical support. 

In addition, we suggest that serious consideration be 
given to establishing a BUMED-sponsored continuing 
medical education mini-course in operational medicine. 
This training could be required for all medical officers 
at naval regional medical centers to maintain their skills 
in operational medicine and help assure their readi- 
ness. 

The question of the number of internists required to 
satisfy the Navy's needs and the distribution of these 
internists into the various subspecialties remains to be 
answered. We have wrestled with this problem for 
years and seem to be no closer than before to the ideal 
solution. We agree that we must continue to train, at 
the very least, the same number of internists and medi- 
cal subspecialists as we were training before we phased 
out the programs at Philadelphia. Without any Berry 
Plan accessions, and with the present poor physician 
retention rates, we will be hard-pressed within the next 
two years to provide even reasonable subspecialty 
staffing in our tertiary care training centers. The sub- 
specialist deficiencies projected for our secondary care 
facilities make the Navy Medical Corps uncomfortably 
vulnerable relative to the standard of medical practice 
in the civilian community. 

Finally, it seems that one possible way to expand our 
limited resources is to get more mileage out of our 
trainees in internal medicine. We suggest the following 
career pattern: a basic medicine GME-1 year followed 
by a year of operational duty, and then by two to three 
years of internal medicine residency. Most trainees 
should then be expected to fulfill their obligation as an 
internist in an appropriate assignment before being 
considered for subspecialty training. 

As our last recommendation, we strongly suggest 
that all payback obligations for training become year- 
for-year as they were in the past. 



Utilization of Family Practice 

CDR R.W. Higgins, MC, USNR 
Chief, Family Practice Service 
Naval Regional Medical Center 
Charleston, S.C. 

Family practice is still in its infancy and there are 
many physicians who have not yet been exposed to this 
new specialty; consequently, a variety of misconcep- 
tions have developed. Foremost among these is the fact 
that many individuals believed the family practitioner 
would take the place of the general medical officer. This 
has never been the goal of family practice in the Navy, 
or anywhere in the country for that matter. The family 
practitioner provides comprehensive and continuing 
care to the entire family. He manages preventive medi- 
cine aspects as well as care of acute and chronic 
diseases. In facilities where this is being done 
according to design the plan is working extremely well. 
In Jacksonville, for example, family physicians perform 
very much in line with the philosophies of family prac- 
tice. They have taken over care of the active-duty and 
dependent personnel of six VP squadrons as well as a 
large number of active-duty and retired families in the 
area. 

The success of family practice at Jacksonville is well 
attested to. A letter of commendation was sent from the 
VP wing at Jacksonville to the Chief of Naval Opera- 
tions; along the way, the letter acquired a number of 
outstanding endorsements recommending that family 
practice be made available to operational units and the 
members' families throughout the Navy. Also, the wait- 
ing list for admission to the family practice program 
keeps growing — a reflection of not enough family 
physicians. 

An interesting project was the inclusion in a family 
practice program, on a voluntary basis, of all members 
and families assigned to a destroyer homeported in 
Charleston. The ship's commanding officer, who had 
been a severe critic of the Navy Medical Corps, at his 
change of command ceremony cited the Family Practice 
Clinic as one of the three most important units to sup- 
port his mission. He said this support had done more 
for morale, retention, and increased productivity 
among his crew than any other program he had seen in 
his 17 years of service. 

In another project both crews of a nuclear-powered 
fleet ballistic missile submarine are being included in 
the practice of one of our family practice staff physi- 
cians. Again, the response has been extremely positive. 
The physician is considered a part of both crews and 
occasionally goes to sea for a few days with them, 
although he does not deploy on a patrol with them. The 
security of knowing that their families have a physician 
who accepts the responsibility for family health care 
has given a tremendous boost to the crew's morale. 



U.S. Navy Medicine 



At the Naval Weapons Station, Charleston, we have a 
satellite Family Practice Clinic in the 1,600-family 
housing area. Though only approximately half these 
families are officially enrolled, most of the others have 
required either no medical care or only minimal care, 
which the clinic has provided. The clinic has also pro- 
vided all occupational medicine services, as well as 
military sick call for active-duty personnel. This support 
was accomplished by a staff of three family physicians, 
a nurse practitioner, and a physician's assistant. Again, 
acceptance has been overwhelming. 

At Pensacola, Fla., the Family Practice Program is 
prospering with excellent command support. Recent 
surveys of beneficiaries show an extremely high de- 
gree of acceptance. Letters from all classes of bene- 
ficiaries frequently reach the commanding officer; 
these letters give strong support and encouragement to 
the family practice system of patient care. Not only are 
nonmedical people using the Family Practice Clinic, but 
we are also noticing a significant increase in the num- 
ber of physicians who are adopting the Family Practice 
Clinic as their basis of medical care. 

At the Naval Aerospace Medical Institute, we have 
created an approved elective Family Physician/Flight 
Surgery Program to provide some operational extension 
for the career-oriented Navy family practitioner. In- 
quiries from medical students are significantly increas- 
ing in this area. The first two family practice flight 
surgeons graduated this summer. Two more residents 
have entered the program. This is a step towards com- 
bining family practice with specific operational billets. 
At Camp Pendleton, Calif., the Family Practice Pro- 
gram has the unique task of providing primary care to 
the largest Marine amphibious base in the world. We 
not only care for dependents but also for a large num- 
ber of unmarried active-duty personnel. 

Since its inception the number of families signing up 
for family practice has grown considerably, with long 
waiting lists attesting to the increasing popularity of the 
program. It has become clear to me that such patients 
are most grateful for the type of care that stresses com- 
prehensive care of the entire family, on a continuing 
basis, by one specialist. 

These are examples of results at the four family 
practice training hospitals where command support has 
been excellent. (A large part of our success is directly 
related to the strong, sincere support given us by other 
specialties.) But elsewhere in the Navy the story is not 
so good. Assignment of family physicians has been as 
groups rather than singly, which is a good concept. The 
family physician assigned alone has, in all cases, been 
used as a general medical officer. But even where 
assigned in groups, family physicians have not been 
allowed to practice in the concept of family practice in 
most cases, and this has led to dissatisfaction and poor 
retention. 

A few more misconceptions must be addressed. 
Family physicians do treat single active-duty members. 



Family in such cases is defined as a single-member 
family, although for statistical purposes we count four 
single members as one family. We also treat widows 
and other single-member families, such as dependent 
children or the child of a divorced couple. 

Another misconception concerns psychiatry. We do 
not practice psychiatry per se, but we do address be- 
havioral problems such as alcoholism, marriage prob- 
lems, school problems, and minor emotional problems. 

Another misconception is that family practice does 
not support the operational forces, We do provide care 
for crewmembers and their families in many varying 
situations, and our residents in all four programs are 
exposed to operational medicine as an integral part of 
their training. 

People who have observed family practice in its 
proper environment can attest to its success and value. 
But to be a viable specialty, family practice by its very 
nature must depend on the support of all other special- 
ties. Naturally, this support must come from the spe- 
cialists who help train our residents, but must also be 
present in the form of consultation and continuing med- 
ical education in all naval facilities. For those of you in 
other specialties who have strongly supported family 
practice, we are appreciative. For those of you who still 
question the validity of family practice, we ask that you 
look objectively at those who are more closely associ- 
ated with this new specialty. Family practice has a 
definite place in Navy medicine, but it must be ac- 
corded the right to follow its philosophies to the same 
extent that other specialties follow theirs. Family prac- 
tice must also have the continued support of all other 
specialties in order to survive in the Navy. 

Preservation of Identity of 
Operating Specialists 

CAPT F.E. Dully, Jr., MC, USN 

Flight Surgeon 

Naval Aerospace Medical Institute 

Naval Aerospace and Regional Medical Center 

Pensacola, Fla. 

Operational medicine is more than the availability of 
a hospital bed for every sick sailor and Marine. The 
continued existence of a recognizable, dedicated cadre 
of appropriately trained naval medi 'al officers who 
have selected as their primary mission medical support 
to and in the fleet or the operational forces is in the best 
interest of the Navy Medical Department. The line has 
come to recognize that the practice of medicine in the 
field, at their side, is a highly visible and indispensable 
form of support. 

For the last 15 years, one branch of preventive medi- 
cine, recognized as a certificated board specialty, has 
had fleet visibility while functioning within the con- 



Volume 68, February 1977 




SAC 8 Speakers: (top) CAPT Early de- 
scribes Navy need for computerized 
tomography; RADMs Elliott and Rup- 
nik participate in panel discussion; 
(bottom from left) CAPTs Cordray, 
Castell, Miller 



straints of the non-hospital operational milieu. Other 
areas of Medical Department responsibilities in the 
fleet arena were filled by similarly devoted physicians 
who made a choice between the practice of medicine in 
the Navy and the practice of Navy medicine but, as in 
the case of aerospace medicine, were unable to supply 
the numbers required to fill existing billets. 

Though their work has not always been recognized as 
valuable, these operational physicians, serving by 
choice in the field, made a contribution, freely offered, 
worthy of recognition and emulation, in a field that 
some members of the profession found relatively un- 
challenging or unrewarding. A health care delivery 
system for a population of pre-screened, ostensibly 
healthy adults included not only the care of the acutely 
ill and the worried well, but also preventive measures 
and planning for such mundane problems as sanitation, 
mass casualty control, environmental stress, occupa- 
tional medicine, and the man-machine interface. 
Where these medical talents were not available, the 
jobs went undone. The line has rightly identified these 
unfilled billets as worthy of our attention. 

At the same time, involvement of our hospital con- 
freres in accomplishing this task offers the opportunity 
to bridge the gap between these two "town-and-gown" 
elements, and to increase mutual respect between the 
two groups. Physicians in operational areas absolutely 



need the recognition and support of their hospital col- 
leagues, and vice versa. 

Physicians in operational medicine sometimes make 
do with less than optimal settings and equipment, con- 
fident of hospital backup. Hospital-based physicians 
bring to bear for us, on demand, all that modern facili- 
ties and talent can offer. Each group needs the other. 
Each is in his place by choice. Each has a worthy mis- 
sion. Each is proud of his role, and each basks in the 
recognition of his patients or the people he serves. 
Some physicians in both groups boast of American 
board certification as professional credentials. 

By blending these two disciplines, a broader based 
practitioner can emerge who is more clearly identified 
with the U.S. Navy. The proposed hospital educational 
contact can only increase the professional stature of the 
operational physician, while the newly cross-trained 
clinical colleague can share the operational identity, 
learn firsthand the limitations imposed by the opera- 
tional milieu, and better support the fleet on his ulti- 
mate return to the hospital. 

Our career medical officers must be as comfortable 
serving aboard ship and on line staffs as they are in 
hospitals and clinics. They must learn to manage a 
health care delivery system, not a sickness care de- 
livery system. They will then be truly Navy medical 
officers, not just physicians in the Navy. 



10 



U.S. Navy Medicine 



Adaptation of the Internship 
To Fit Navy Requirements 

CAPT D.R. Cordray, MC, USN 
Department of Pathology 
Naval Regional Medical Center 
Portsmouth, Va. 

We members of the Internship Committee have 
noted the theme of accountability presented here and 
the accentuation of the importance of operational medi- 
cine. Our main proposal, therefore, is to recommend 
that the G-l year be tailored to better match the needs 
of the fleet and the Marine Corps. At the same time, 
the first-year graduate experience should provide op- 
portunities for young physicians to learn more about 
the various medical specialties and to develop profes- 
sional maturity. 

We propose a flexible program which would include 
medicine, surgery, orthopedics, one month in the emer- 
gency room, at least minimum experience with anes- 
thesiology, and two to four months of electives. The 
electives should be individually planned clinical 
rotations designed to provide experience in clinical 
areas that may not have received adequate attention 
during medical school. 

If the foregoing plan were to be adopted throughout 
the Navy, we would recommend that scholarship partic- 
ipants be made aware of this policy and of the likelihood 
that they would be required to serve at least one year of 
operational duty prior to residency assignment. 

We also believe that senior students who have a par- 
ticular residency interest should discuss their G-l rota- 
tions with the prospective service chief prior to sub- 
mitting their questionnaire to the intern coordinator. 
This may permit the inclusion of electives which would 
be useful in their proposed residency as well as com- 
patible with a year of general duty. 

With regard to intern indoctrination, the Committee 
believes that a two-day to three-day indoctrination pro- 
gram for incoming G-l physicians should be offered at 
each teaching center. This program should include 
orientation to the Navy as well as to the Medical De- 
partment and the individual medical center. We 
recognize that indoctrination programs are offered at 
the various hospitals, but we believe these programs 
should be organized and coordinated. 

We suggest that graduating medical students be 
ordered to duty during the last week in June so they can 
complete indoctrination and other preparations before 
assuming intern duties on 1 July. Some thought should 
be given to more specific orientation to the appropriate 
operational training programs or assignments during 
the intern year, for we note that other committees have 
come up with the same idea. This could be done on an 
individual basis or in small groups as the workload per- 
mits, and should not displace or interfere with didactic 



or practical medical education. Each intern preceptor 
should be furnished with up-to-date brochures provid- 
ing information on submarine medicine, aerospace 
medicine and other programs. 

This coming year some 97 scholarship graduates will 
not get Navy intern assignments. Those students who 
will not be deferred for residencies after their first post- 
graduate year should be informed at the start of the 
year that they will be expected to assume all-around 
medical responsibility, and that they should plan their 
internships accordingly. 

We believe that these duty- oriented G-l rotations 
will meet American Medical Association specifications 
for flexible internships. Such a flexible program will 
best serve both the young physician and the needs of 
the Navy. 

The Essential Continuum of 
the Pediatric Residency 

CAPT D.W. Bailey, MC, USN 
Chief, Pediatrics Service 
National Naval Medical Center 
Bethesda, Md. 

The Pediatric Specialty Committee chose for its ten 
minutes to share with you a dilemma we have con- 
fronted in the past year. As many of you already know, 
the American Board of Pediatrics decided several years 
ago not only to disapprove the concept of the free- 
standing internship but to remove the word intern from 
its vocabulary. This has caused frequent confusion in 
graduate medical education meetings. Students who 
enter pediatric training straight out of medical school 
are now designated pediatric level one or PL-1 resi- 
dents as far as the American Board of Pediatrics is con- 
cerned. This change coincided with the Navy's decision 
to phase out free-standing or rotating internships, so all 
went well for a short period. Now, however, the needs 
of the Navy dictate a return to the basic internship to 
prepare to meet our operational commitments. 

The challenge which faces us, then, is to compensate 
for this diverse swing of the pendulum while avoiding 
any weakening of our four residency programs and 
maintaining the strength of Navy pediatrics. 

In way of background I should mention a few inter- 
esting aspects of this problem. First, as far as can be 
determined, and assuming no major change in our eli- 
gible beneficiaries, the pediatric workload in the future 
will be considerable. We continue to provide a major 
portion of the care to ambulatory patients, even when 
family practitioners are present in the same facility. At 
present we estimate that we are about 25 pediatricians 
below our optimum numbers. This is about 9% of our 
ideal level for patient care. This shortfall can be pro- 
jected to increase to approximately 20% in Fiscal Year 



Volume 68, February 1977 



11 



1978 and possibly 40% in Fiscal Year 1979. We must, of 
course, do what we can to minimize this trend in the 
face of our operational and other commitments. 

Before 1975 a pediatric trainee could become board 
eligible by satisfactorily completing a nonpediatric G-l 
year plus two years of pediatric residency. But now all 
individuals who began training on or after 1 July 1975 
are required to have three years of clinical pediatric 
residency to be board eligible. It is the strong and 
unanimous belief of the Navy pediatric program direc- 
tors, a belief supported by our board's representatives, 
that three years of pediatric residency training should 
be in a continuum in time. 

Another problem that we have become acutely aware 
of this week is with the PL-2 or pediatric level two ap- 
plicants. There appear to be an increasing number of 
these individuals. We had four or five this year and at 
least nine last year. They have been brought on active 
duty following a year of pediatric training in a civilian 
institution and are now applying for nonexistent 
second-year openings in our programs. Obviously, this 
creates a major problem for such individuals when they 
complete their training. It is also equally obvious that 
the optimal continuum of which I just spoke is lost. 

Finally, to address the major issue of our operational 
needs, our requirement to train pediatricians must, of 
course, be balanced against our urgent requirement to 
provide appropriately trained physicians for operational 
billets. We have, therefore, come up with a proposal, 
the goal of which is to ensure insofar as possible a con- 
tinuum of training for all applicants to Navy pediatric 
residency programs. 

Program applicants can be considered as falling into 
one of two major categories: applicants from the field, 
and applicants who have just graduated from medical 
schools. Some of the applicants from the field may not 
have had a year of pediatric training — the so-called 
PL-0. We believe that as many of these as possible who 
are qualified should be matched to PL-1 openings and 
offered a three-year contract. This, of course, reflects 
no change in present policy. 

Another group had completed a single year of 
straight pediatric training and had then been brought 
on active duty to serve in operational billets. These 
physicians should be counseled immediately and con- 
sistently to consider applying for PL-1 and PL-2 
openings (the latter are extraordinarily scarce). This 
may add one year to their graduate medical education, 
but we don't see any other way to resolve the acute 
dilemma. We expect, however, that the proposals that 
follow should, over the next two to three years, reduce 
this unfortunate group of individuals to zero. 

As far as medical student applicants are concerned, 
we propose that a carefully selected number be allowed 
to fill any PL-1 vacancies that exist after all selections 
have been made from applicants from the field; these 
students should be given a three-year contract, as has 
been our policy. It can be assumed that the number of 



students required to maintain program strength and 
quality will be very small in the next one to two years. 
Parenthetically, this year students fill substantially 
fewer than 50% of the slots, a steady decline that 
should continue. As the number of qualified applicants 
from the field increases, medical student selectees 
should drop to zero. 

Medical school applicants who are not selected for a 
full pediatric residency should be counseled to seek a 
Navy basic medical or bask surgical internship as a 
preferred alternative to prepare for an operational tour; 
after this tour, they may reapply for a three-year pedi- 
atric residency. 

Students not selected for any Navy G-l program 
should be divided into two groups according to pro- 
jected needs for general medical officers versus pedia- 
tricians. One group could be given a three-year defer- 
ment, as necessary, to complete pediatric training in a 
civilian program before being called upon for active 
duty. The remainder should be encouraged specifically 
to seek a diversified civilian internship, not a civilian 
PL-1 internship, which will prepare them for their 
operational tour; after their tour they may apply for a 
full pediatric residency. 

A brief comment on the impact these recommenda- 
tions might have: Ultimately, these recommendations 
could result in as many as 16 additional training billets, 
since the numbers of graduating students permitted to 
enter directly into Navy or civilian pediatric residencies 
and to complete these residencies without interruption 
can be expected to decrease over the next few years to a 
minimal level, if not to zero. On the positive side, we 
believe that with this policy pediatric trainees will 
become more mature, career-oriented physicians with a 
heightened awareness of the overall needs of the Navy 
Medical Corps. They will also have the background, 
experience, and training they need to be better naval 
officers and to participate more competently in the 
operational aspects of our mission. 



Audiometry Screening 

CAPTT.F. Miller, Jr., MC, USN 
Chief, Department of Otolaryngology 
Naval Regional Medical Center 
Oakland, Calif. 

The line item cost of compensation for hearing loss 
paid to civilian and military employees of the Depart- 
ment of the Navy is greater each year than the opera- 
tion and maintenance budget of most of our naval 
regional medical centers. We must exert a concentrated 
effort to reduce this needless expenditure — an effort 
which will, at the same time, reduce the number of dis- 
abled and handicapped service members and Navy 
employees. 



12 



U.S. Navy Medicine 



Nine years ago I was asked to help with the revision 
of BUMED Instruction 6260.6B. The impetus for this 
revision was an increase in the number of legal actions 
on the part of civilian and naval workers. Unfortunate- 
ly, these actions have continued and, I am sorry to say, 
are often settled disproportionately in favor of the indi- 
vidual on the basis of unscrupulous or inadequate find- 
ings by some of our civilian colleagues. Equally un- 
fortunate is the all too common discrepancy between 
disability payments, which are excessive for the civilian 
Navy employee and probably nonexistent for the active- 
duty member with the same degree of hearing loss. 

BUMED Instruction 6260. 6B provides adequately for 
identification and protection of the noise sensitive indi- 
vidual. Legislative action implementing Occupational 
Safety and Health Act (OSHA) regulations further 
directs us to comply with the altruistic and practical 
concepts of comprehensive hearing conservation pro- 
grams. Issuing ear ■ plugs and advising annual 
audiograms without adequate follow-up falls far short 
of what is required. 

Our recommendations follow the accepted format 
being used in some civilian industrial communities. 
Initial hearing testing and record keeping will be done 
by audiometric technicians who will work under the 
supervision of specialists in environmental health. Con- 
sultative services and the necessary training for these 
technicians will be provided by audiologists and 
otolaryngologists from the departments of otolaryngol- 
ogy in the regional medical centers. In three separate 
courses at NRMC Oakland, we have already trained 36 
audiometric technicians who are eligible for certifica- 
tion. These people are actually working in the region. 




Leading his first conference as Surgeon General, VADM 
Arentzen considers the views of a SAC B participant. 



To satisfy the requirements with which we are being 
tasked, we need medical officers in the field who are 
educated in hearing loss, the interpretation of audio- 
grams, and the effects of noise pollution. It is manda- 
tory that all basic medicine and basic surgery interns 
spend at least one month on an otolaryngology rotation. 
Besides becoming familiar with hearing problems, 
these physicians will be better qualified for duty in the 
field and with the fleet, since several studies of com- 
plaints presented to primary care physicians show more 
than one-third to be related to ear, nose, and throat. 

Additional audiologists will be required in each 
region. We suggest commissioning them as Medical 
Service Corps officers as the Army and Air Force do. 

Each program would be operated at a regional level. 
It would be mandatory that noise sensitive individuals 
be removed from noise-hazardous areas upon the 
recommendation of a competent otolaryngologist. 

On the Necessity for 
Computerized Tomography 
in Naval Hospitals 

CAPTC.B. Early, MC, USN 
Chief, Neurosurgery Service 
National Naval Medical Center 
Bethesda, Md. 

Computerized tomography of the intracranial con- 
tents is not just a significant improvement in the 
methodology of diagnosis in neurological disease. It is a 
quantum leap forward in this area. Its importance in 
neurological disease is considered by many to be equiv- 
alent to the introduction of antibiotics in infectious 
disease management, or to digitalis in the field of car- 
diology, or the introduction of modern techniques of 
anesthesia or aseptic technique in the field of surgery. 

Basically, computerized tomography is merely the 
application of computer science to radiographic tech- 
niques. Rather than photographic plates, electronic 
sensors are used to detect the intensity of X irradiation 
passing through the tissue to be studied. As in conven- 
tional tomographic techniques, each point in the tissue 
to be studied is subject to transmission of X irradiation 
from different directions. The most common method in 
use today is to pass the X-ray beam through the tissue 
from 180 different angles, each one degree apart. Then 
the quantitative value of transmission for each point for 
each angle is multiplied by the similarly determined 
value for each of the 180 different angles. 

Thus, differences in X-ray transmission are raised to 
the 180th power. Where very small differences in X-ray 
transmission may not be discernible on the usual X-ray 
plate, they become almost as clear as the difference be- 
tween black and white when raised by computer to the 



Volume 68, February 1977 



13 



180th power and displayed electronically. 

The value of applying this technique to intracranial 
diagnosis has proven itself beyond any reasonable 
challenge in practice. In a large series of cases at the 
Mayo Clinic and the Massachusetts General Hospital, 
where equipment of this type has been in use for nearly 
three years, the yield rate — that is, the ability of the 
technique to delineate structural change due to intra- 
cranial pathology — is higher than either air or positive 
contrast encephalography, radionuclide scanning tech- 
niques, angiography, or all of these methods in com- 
bination. The rate of corrected diagnosis for com- 
puterized tomography alone is 96% or better. 

Computerized tomography (CT) is not only capable of 
delineating the difference in radiodensity between 
tumors or other pathologic entities and normal struc- 
tures, but also of showing the configuration of normal 
structures. The ventricular system, the cerebrospinal 
fluid subarachnoid cisterns, gyri, and sulci are clearly 
seen. Structures as small as the cranial nerves, 
medium-sized vascular structures, and the extraocular 
muscles are delineated. New developments in im- 
proving spatial and density resolution make it possible 
to distinguish grey matter from white matter. 

With all of its advantages, CT is a truly minimal risk. 
Radiation dosage to the head' is in the range of about 
two rads. Used without enhancement, it is totally 
noninvasive. Using enhancement — a process whereby a 
radiopaque medium, such as hypaque, is placed in the 
bloodstream to increase the radiodensity of relatively 
vascular tissue or areas of breakdown of the blood-brain 
barrier — the degree of invasiveness is only equivalent 
to that of an intravenous pyelogram. 

One of the most important uses of CT is in the area of 
acute trauma. The presence of an expanding intra- 
cranial clot can be determined in five minutes, whereas 
previously angiography was required to provide such 
information — at a cost of one to two hours and a con- 
siderable increase in manpower required. Such delays 
can easily mean the difference between life and death, 
or perhaps even more important, between useful and 
useless life. 

I have not addressed the subject of whole body com- 
puterized tomography primarily because it is obviously 
not within my purview. Though it has not been well 
proven, as compared to cranial CT, it shows consider- 
able promise. When certain difficulties arising from 
motion and air-filled cavities are overcome, it may con- 
ceivably become as valuable as cranial CT. As spatial 
resolution improves, its value in intraspinal and orbital 
diagnosis is becoming evident. 

Computerized tomography is cost effective. Where 
properly used, it has been shown to dramatically de- 
crease the number of more invasive, high-risk, and 
equivalent or higher cost diagnostic procedures. Angi- 
ography is usually reduced by a factor of about one- 
third. Ventriculography and pneumoencephalography 
are reduced to only about 20% or 25% and radionuclide 



scans to about one- third of the number required before 
utilization of CT. Savings in these areas alone are 
capable of defraying the cost of CT, especially con- 
sidering the savings in manpower. The revenue derived 
from CT in institutions where it is used on a fee-for- 
service basis amortizes the cost of the equipment in 
short order. Most facilities find that although amortiza- 
tion may have originally been programmed for two to 
four years, it is usually achieved in less than half that 
time. 

Present rates for CT scanning range from $200 to 
S400. Because of its cost effectiveness, civilian hospital 
administrators not only greet it with open arms, they 
work diligently to obtain it. Installation of CT equip- 
ment in military facilities has lagged woefully. Nearly 
three years have elapsed since initial inquiries were 
made into the possibility of obtaining units, but the first 
unit has yet to be installed in any U.S. military medical 
facility. We hope that the Navy's first CT unit will be 
installed in NRMC San Diego next April. 

The standard of practice in the treatment of neuro- 
logical disease has, for at least a year, required the use 
of CT. The neurological disease population is well 
aware of the capability of CT. It is neither morally nor 
ethically proper, nor professionally proper, to subject 
someone to a more invasive, more uncomfortable, more 
. risky procedure when the diagnostic power of CT is 
available. Furthermore, in some cases such substitu- 
tion is impossible, because the knowledgeable patient 
will not accept it. 

The lack of CT capability in our hospitals has already 
cost us countless hospital days. What do you do with a 
patient aeromedically evacuated to Bethesda from 
Florida for neurological diagnosis, when you find the 
earliest he can be scheduled for CT at the National 
Institutes of Health is six weeks hence? 

CT is required in all naval hospitals charged with the 
management of neurological disease. It has been sug- 
gested that perhaps these hospitals should obtain CT 
services from other facilities in the vicinity. Such rea- 
soning is fallacious. In all institutions where CT has 
been installed, its use has rapidly increased until equip- 
. ment time is at a premium. Frequently this has resulted 
in a second or third unit being obtained. Such has been 
the experience at NTH where, despite the presence of 
three units, routine CT service available to Bethesda 
(which is right across the street, as close as you can get) 
takes about six weeks to obtain, and absolute emer- 
gency service takes about four days. This experience 
clearly, and I believe irrefutably, demonstrates the 
need for our medical facilities charged with treating 
neurological disease to have their own units. As a 
matter of fact, it might be more realistic today to be de- 
bating how many units each of our facilities should 
have, rather than whether we need the first unit. 

Obviously, the proper standard of treatment of acute 
craniocerebral trauma cannot be effected today without 
CT being in-house. It is inconceivable that proper 



14 



U.S. Navy Medicine 



management of such trauma would include calling 
for an ambulance, waiting for its arrival (if one is 
available at all), loading a patient on it, taking the 
patient to a nearby facility, unloading the patient and 
taking him into the facility for CT, loading him back into 
the ambulance (assuming it is still available), and 
bringing him back to our facility for treatment while an 
intracranial bleeding point causes an expanding blood 
clot to further compress an already seriously sick brain. 
CT must be in-house. 

CT must be provided in-house for training purposes. 
Board examinations in the three specialties — neurol- 
ogy, neurosurgery and radiology — will include material 
on CT by 1977. Are we to send our residents outside the 
service for this training? 

In summary, it is strongly recommended that the 
schedule for equipping our facilities with CT be accel- 
erated, and that all facilities charged with the treatment 
of neurological disease be provided CT equipment at 
the earliest possible time, certainly no later than Fiscal 
Year 1979. 



Oral Surgeons Committee 



CAPT T.W. McKean, DC, USN 
Chief, Oral Surgery Service 
Naval Regional Medical Center 
Oakland, Calif. 

One subject we discussed was the level of manning 
and utilization of all personnel with oral surgery train- 
ing. It was recommended that Navy requirements for 
oral surgery training be reviewed in order to develop a 
staffing formula for training oral surgeons in the Navy 
Medical Department. 

Additionally, to help the Bureau of Medicine and 
Surgery identify appropriate officers for oral surgery 
education assignments, our committee reviewed the 
qualifications of eligible, trained oral surgeons who 
might be considered for future teaching staff assign- 
ments. 

The general practice residency programs in dentistry 
conducted at our naval teaching hospitals were 
reviewed, as were the methods of instruction. We 
believe these programs are valuable to better prepare a 
general practice resident for service with the opera- 
tional forces. It was further recommended that, in keep- 
ing with the intent of existing directives, a standardized 
hospital orientation procedure lor general practice resi- 
dents be implemented at all our training hospitals. 

Another big item particularly important this year to 
all parts of the Medical Department is credentialing. 
Our committee's strong opinion was that dental offi- 
cers should be included on credentialing committees at 
all naval hospitals. It was recommended that in smaller 
hospitals additional qualified dental officers be brought 



in from the dental regions to help credentialing com- 
mittees review qualified applicants for the delivery of 
dental health care and to assist the commanding officer 
in his credentialing. 

Another important area is operational medicine. 
Operational rotation of oral surgery residents was dis- 
cussed; such rotations were highly recommended as an 
integral part of each training program in order to 
enhance the training indoctrination of naval oral sur- 
geons. This practice will better prepare oral surgeons 
for duties with the operational forces and also for their 
return to assignments in naval hospitals. 

Radical Approach to 
Health Care Delivery 

CAPT H.J. Sears, MC, USN 
Chief, Psychiatry Service 
Naval Regional Medical Center 
Portsmouth, Va. 

Let me begin by saying that this is not in any way a 
radical approach. It is how I see the reality of our situa- 
tion, some of the implications and some possible ap- 
proaches for change. These approaches might seem 
radical in the shift of money, training and person power 
that they imply. 

The issue I want to present today is simple. It is not 
new, yet it is repeatedly overlooked and denied. It has 
profound implications for our Navy health care delivery 
system. The issue is this: A conservative estimate indi- 
cates that the number of people with no significant 
organic illness who enter health care systems is some 
40%. (There are studies by Locke and Gardner in 
Public Health Reports and Rosen and Goldberg in 
Mental Hygiene, among other sources.) Stated another 
way, this is the problem of the nonmedical patient — the 
"worried well" — in the medical setting. 

In Navy medicine the percentage is probably higher. 
Duffy in his work at NRMC Portsmouth found that 34% 
of people entering an acute minor illness clinic had as 
their major problem a direct emotional or social prob- 
lem. Duffy estimated that another 30% to 40% pre- 
sented problems that did not actually require medical 
attention, but got such care, anyway. Much to our sur- 
prise, an informal study in a specialty clinic — not a 
psychiatry clinic — with referral only by physicians re- 
vealed that nearly 90% of patients had non-organic 
problems. 

So for the sake of discussion let us say that 50% of 
the people entering the Navy health care delivery sys- 
tem present problems that reflect social and emotional 
needs rather than organic medical needs. 

Recent well-documented studies indicate that in 
certain quality teaching hospitals 40% of the inpatients 
have what are essentially social and emotional needs 



Volume 68, February 1977 



15 



rather than organic medical needs. I believe that our 
hospitals probably reflect the same, if not a greater 
percentage. Nonsense, you may say, but the evidence 
is overwhelming. 

We are all aware of the problem. The physician work- 
ing in a busy clinic can spend approximately 10 minutes 
per patient or fall irretrievably behind with his work- 
load. He has no time to really discuss problems with the 
patient. If there is significant organic disease, the phy- 
sician usually spots it and does something definitive. If 
there aren't significant findings, he often ends up 
prescribing something, often Valium, or getting lab 
tests. The patient then leaves, with no resolution of the 
real problem, to return yet another time with the same 
need, to yet another medical officer, only to go through 
the same process. Eventually, if the patient is persist- 
ent enough or troubled enough, admission may ensue, 
with a further negative workup and the diagnosis, 
"There's nothing wrong with you." The process con- 
tinues. Part of this distillate ends up in specialty clinics 
for more workup and sometimes for "definitive sur- 
gery." 

My thesis is that approaches can be developed to 
deal more directly with these patients with less ex- 
pense, less drain on precious Medical Department 
manpower, more definitive care, and greater provider 
and consumer satisfaction. In other words, quality 
health care. 

You ask, how do we do this? I think there are many 
approaches to finding satisfactory solutions. Here are 
some steps which I believe need to be carefully con- 
sidered: 

The first step requires a major attitudinal change in 
health care delivery. We have to stop ignoring and 
denying the preeminence of social and emotional deter- 
minants of illness and illness behavior. There is suffi- 
cient evidence to document this. It is not simply a mat- 
ter of opinion, it's a matter of fact! The problem lies in 
the realm of our own mental set and in the things that 
make us feel secure, not wanting to change the status 
quo. 

Since World War II, American medicine has been 
characterized by burgeoning specialization and sub- 
specialization. This has caused fragmentation, discon- 
tinuity, and impersonality in the delivery of health care. 
There has been an emphasis on cure rather than care. 
The tendency of specialists to congregate in hospitals 
has contributed to geographic maldistribution and has 
limited access to medical care for some segments of our 
population. This is where medicine is, nationally and in 
the Navy. 

We need to return to concern for the careful history 
and the thorough physical exam, and to reserve the 
"million dollar workups" for patients who really need 
them. We need to move our specialists, staffs, and res- 
idents to outpatient and branch clinics where they can 
be accessible to patients for primary care. There spe- 
cialists will be readily available to the general outpa- 



tient staff for on-site consultation. There is a need to 
educate all Medical Department personnel in the soci- 
ology of the Navy health care system and its benefi- 
ciaries, and in the social and emotional factors in illness 
— its onset, assessment and management — as well as 
illness behavior. We need to get our scarce supply of 
doctors, nurses, corpsmen and other medical support 
personnel back to the front lines where they are needed 
and out of the inaccessible and congested hospitals and 
centers where they have congregated. We need to 
regionalize in fact, rather than on paper. We need 
medical care accessible to the patients, not simply for 
the convenience of our administrators and doctors. 

We do not need the creeping specialization and sub- 
specialization we now have. We need more primary 
care physicians now, and we need them where the pa- 
tients are, not where we would like them to be. 

There is an urgent requirement for more social 
workers and a referral network to handle the problems 
of living and the more serious emotional and social 
problems at the entry level. We need the support of the 
line Navy, who should take more interest in the main- 
tenance of health. We must make it clear to line man- 
agers what they can do to promote health. 

The Navy health care system is facing the same prob- 
lems that medicine in general is facing in this nation: 
maldistribution of physicians, overspecialization, not 
enough primary care physicians, no continuity of care, 
dissatisfied consumers, horrendous costs. But we have 
a unique opportunity to develop a major health care 
system that takes sensible approaches to the resolution 
of these problems. We need to stop being defensive. 
We can develop a responsive and supportive relation- 
ship with the line that will make Navy medicine not only 
not threatened, but absolutely indispensable. We must 
develop a health care system in which primary care 
physicians are more than just the guys who have to take 
care of those patients who are not particularly interest- 
ing. We must have a system that does not define 
quality care in terms of our ability to treat serious 
disease well, especially when the overwhelming major- 
ity of our patients do not have serious diseases. 

Manpower Requirements in 
Highly Specialized Services 

CAPTC.F. Bishop, MC, USN 
Chief, Pathology Service 
Naval Regional Medical Center 
San Diego, Calif. 

It is the opinion of specialized services such as sur- 
gery, urology, pathology and radiology that our most 
critical problem concerns support personnel for our 
professional staff. The support is primarily technical, 
but in some specialties the requirement is also in the 



16 



U.S. Navy Medicine 










^pi^^ 




L V* 


J^ ^ 












^m\ 








Clockwise from top left: RADM Cox; RADM Corxter; CAPT Sears; CAPT McKean; CDR Higgins 



professional category. The demands resulting from in- 
creasing sophistication of our medical care procedures 
affect all services within our medical centers and non- 
teaching hospitals. 

The increased numbers of surgical procedures in our 
operating suites have been occasioned by the develop- 
ment of programs in cardiothoracic, vascular, and 
oncologic surgery, and by new neurosurgical and joint 
replacement procedures. These procedures, simply by 
their nature, require increased numbers of support 
personnel and extended time; they cannot be managed 
in the standard eight-hour working period. Cancellation 
of cases and delays are frequent. Therefore, to provide 
services in support of our patient care and teaching 
commitments the Surgical Committee felt an overlap- 
ping shift system was needed for operating room 
nurses and technicians. This system would provide 
better coverage during peak hours and would allow the 
operating day to be extended as necessary. 

In the practice of urology there are similar problems 
in providing services to patients. The ratio of urology 
technicians to professional staff in most of our clinics is 
less than 1:1. In some areas there is only one technician 
for every two professional staff members. Our commit- 
tee believes that, for a urology service to be effective, a 
ratio of four technical personnel to one professional 
staff member is in order. The service will then be able 
to accomplish the cystoscopies and laboratory and 
radiographic procedures that are done in clinics, as well 



as to maintain equipment for patient use day to day. 

Laboratories throughout the Medical Department are 
in critical condition, primarily from the technical stand- 
point. Analysis of productivity shows that most of our 
technical people and our civilian employees within the 
laboratories are producing three times above the 
national average. There is relatively little prospect of 
relief for us at this time. Review of quality assurance 
programs in the laboratories during 1976 has shown 
progressive deterioration in the quality of work. It is not 
by choice that this is happening to us. 

Radiology services are experiencing some of the 
same problems we see in laboratories. But their most 
critical problem is the prospective deficit of approxi- 
mately 26% among trained radiologists in Fiscal Year 
1977, with a prospect of greater deficits in 1978. This 
will produce marginal service at best and may even re- 
sult in loss of service in some areas. Professional re- 
cruitment for radiology is difficult and prospects for 
filling our vacancies are bleak since the enticements 
and incentives of the civilian community are so great. 

The effect of manpower deficits is recognized readily 
by each specialty. The danger of error is ever present 
when there is less than optimal patient care support. 

Inadequate support in specialized areas may also 
seriously affect our graduate programs. As we all 
know, certain specialties require specific numbers of 
operative procedures for accreditation of training pro- 
grams. Program accreditation may be lost if staff-to- 



Volume 68, February 1977 



17 



resident ratios fall below the required level in 
radiology. Vertical cuts in services to align manpower 
with production would virtually eliminate training in 
programs such as pathology, radiology, and the sur- 
gical specialties. 

Legal problems may arise. For example, there are 
requirements that a circulating nurse be present within 
an operating room when a patient is being treated. 
Errors in diagnosis because of low quality laboratory 
results could produce malpractice situations and per- 
haps costly legal encounters. 

Federal legislation may be applicable to us, now and 
in the future. Occupational health and safety support is 
now required to meet the standards and regulations of 
the Occupational Safety and Health Act. Impending 
legislation may require set educational and experience 
levels for support personnel in federal institutions. We 
are closely watching federal legislation that may apply 
to laboratory services. 

Again, our committee believes that significant in- 
creases in operating room nurses and technicians would 
enable operating rooms to overlap shifts and extend 
hours in which surgical procedures are performed. 
Such a change would affect not only surgical specialties 
but also other areas, particularly anesthesia. 

Authorizing and billeting technical personnel on an 
accepted work unit basis might be a requirement; or 
contractual arrangements could be introduced to 
reduce volume and meet accepted standards. Contract- 
ing radiology services might be considered, for exam- 
ple, as might discontinuing radiologic services to 
non-active-duty beneficiaries, particularly at nonteach- 
ing hospitals. We might also develop radiologic techni- 
cian expanders to assist radiologists. The radiological 
group has also considered the possibility of establishing 
a training program at NRMC Portsmouth to increase 
the number of Navy radiologists. 

I think we all recognize that accomplishing any of 
these recommendations would be a monumental task, 
and in some areas would not be possible. The total 
Navy manpower situation has prospects of further 
reductions, not only in military authorizations and 
manning levels, but also in Civil Service ceiling points. 

One final recommendation is in order: we should ap- 
proach the future with confidence, with optimism, and 
with the self-assurance that we will continue to provide 
the best care we can with the resources we have. 



DISCUSSION 

CAPT Good; Admiral Arentzen, you have heard the 
reports from some of the committees this morning. Would 
you care to respond to any of their statements? 

VADM W.P. Arentzen, MC, USN: I am going to ask the 
members up here to respond to specific things. I think that 
first 1 will ask Admiral Rupnik to comment. I will let him 
get started and then go down the line with certain things that 
1 want done. 



RADM E.J. Rupnik, MC, USN: I look ahead with optimis- 
tic skepticism or skeptical optimism with regard to what may 
be done for us in the future, because we are tied to the line 
budget. They will help us out to the extent they can, but they 
can't give us more than they are getting themselves. This is 
particularly true with regard to personnel. I know that all of 
you fully appreciate the limitations that are placed on the 
Bureau of Medicine and Surgery, particularly in the enlisted 
areas. We just do not have enough enlisted support to fulfill 
the total requirements that are placed on us. There is going to 
have to be some decision made at some future date as to 
where the level of care will be cut off. That remains to be 
seen. 

The notes that I made reflect a feeling of frustration. I think 
we are falling into the same interbellum trap that we have 
found ourselves in before each major war. I don't see the 
emphasis on training to contingency requirements. The 
emphasis that I have heard here this morning has been on 
what are we going to do for primary health care. That is 
important, but remember that we are hired to be available to 
care for all those wounded patients whenever the bombs are 
dropped. 

What are we doing about training surgeons to take care of 
multiple wounds and injuries and burns? Where are the re- 
marks made in regard to the orthopedic specialties? These 
things are of some concern to me. I know that we have placed 
a lot of emphasis on primary care, but perhaps we are over- 
emphasizing it. 

One of the recommendations I thought I heard here this 
morning was that we have got to take vertical cuts in areas 
where there are high numbers of civilian employees. Perhaps 
that would be in the area of obstetrics. I would remind you 
that the obstetrician is one of those individuals who during 
peacetime takes care of our dependents' needs; but in time of 
war he is a good surgeon who can respond to our contingency 
needs. I think that is true of a lot of our specialties. When we 
train we must keep in mind that our ultimate goal is to train 
for the contingency we may have to respond to. 

When we think of the priorities of patient categories, we 
must remember that care of the dependents of active-duty 
personnel is probably as important, or maybe even more im- 
portant, than care of the active-duty man himself. An active- 
duty individual aboard ship or out in the field is not a very 
effective fighting man if he is worried about who is taking 
care of his family back home. So while we may have to curtail 
some care to some patient beneficiary category, 1 don't think 
that we will ever curtail care to the dependent of the active- 
duty member. That goes along with this family practice con- 
cept. The family practice concept should be directed first and 
foremost to the active-duty patient and his family. 

The problem I see is large numbers of retired families 
signing up for the family practice program. And, of course, as 
more active-duty individuals go out, more retirees sign up. 
Pretty soon we would be taking care of all retirees and their 
families, and there won't be room to take care of the active- 
duty member and his family. We must not fall into that trap. I 
know you are all working to avoid that. Commanding officers 
of various facilities are particularly aware of that problem. 

On Tuesday I said that our problems probably began with 
the abolition of the draft. I think our problems in education 
and training also began with the publication of the Millis 
Report. I can't think of any report that has been more 
damaging to us as an institution than the Millis Report. We 
are right back where we were four years ago. We are now 



18 



U.S. Navy Medicine 



talking about an all-purpose type of internship. That is exactly 
what Dr. Millis tried to steer us away from. I don't know how 
many of you agree with me, but I think he was wrong. I think 
we need to go back to the broad-based internship, and begin 
definitive specialty education after the physician serves a 
period in an operational tour. 

Participant: I attended the first SAC meeting. I started as a 
clinician representing the operational forces three years ago, 
and it was three years ago that the need for the increased 
support of the operational forces was identified. Last year 
there was great discussion. This year everybody is in the act 
and we are about to do something about it. Everybody is talk- 
ing about it. 

I agree that we need a rotating internship. We must be 
aware of all the needs of the Navy. Occupational medicine is 
one need, flight medicine is another, submarine medicine 
another, surgery another, psychiatry another. We are all part 
of the same team, and we all need to be welded together. We 
need to be one Navy doing one job. 

RADM A.C. Wflsori, MC, USN: I mourn the passing of the 
rotating internship along with the five-cent cigar. But that is 
not the game these days. As most of you know, I am fresh 
back in the Bureau. A couple of things were immediately 
apparent to me. The language that is used in Washington now 
to fight for resources is very different language from what 
was used just two or three years ago. We are now talking in 
terms of systems. We are talking in terms of models and 
studies. Nobody has any credibility anymore unless he has 
recently seen his analyst, and I don't mean his psychiatrist. 

We are forced on a minute-to-minute, day-to-day basis to 
review in very fundamental terms — that all add up to 
dollars — how and what we are doing. And in every Navy com- 
munity sacred cows are being slaughtered every day as 
people are learning that certain traditional, time honored, and 
very comfortable ways of doing things have to be abandoned 
in favor of better management techniques. 

So that is the business we are in. To make all of this possible 
has required considerable reorganization of the Bureau. Our 
plea to people in the field — or at least my plea as a resource 
representative for you — is to be as objective as you can. Look 
at how you are doing and at what you are doing. Sit on the 
other side of the fence, at least intellectually, and ask your- 
self. Is this task or procedure necessary? Is this the best way? 
What would happen if I didn't do it at all? What would 
happen if I did it differently? 

As you all know, we are not exactly wealthy. We are not 
going to be wealthier to any great degree next year, either. 
However, a couple of good things are happening. We have 
great confidence that we will get more money for major equip- 
ment in the next couple of years than we have gotten in the 
past few years. 

You have all been asked to submit your investment equip- 
ment list, and we have got to have those lists well scrubbed. 
We cannot afford to have a solitary dollar wasted on any piece 
of equipment. Personal wishes are fine, but unless they fit 
into the pattern of utility and productivity to meet the mission 
of your facility, forget it. 

We have some new facilities, and we are getting more of 
them. I was interested to hear the surgical group talk about 
overlapping shifts and getting more mileage out of what we 
have. This is the kind of thing that we all have to do — decide 
how we can get more mileage out of what we have. I am avail- 
able on the phone, if you need to talk with me. 

RADM R.W. Elliott, Jr., DC, USN: I heard a story the 



other day about a father and son who were in church. During 
the church service the boy was looking around and not paying 
attention to the preacher. He saw a stained glass window and 
said, "What is that, Dad?" His father replied, "That is a 
memorial to those who died in the service." The boy thought 
for awhile and then he said, "The eight o'clock service or the 
nine o'clock service?" 

Obviously, they weren't communicating too well at the 
moment. I think Admiral Arentzen has expressed his desire 
that Navy dentists and physicians communicate better and 
more frequently. I am in full agreement with that. 

In the area of credentialing, as discussed by the Oral Sur- 
geons Committee, I fully concur with the recommendations. I 
believe that in medical centers and hospitals where creden- 
tialing committees are established a dental officer should be 
included as a full representative, and a full member of the 
team providing care to patients in the hospital. 

Relative to operational assignments, and to assure that 
general practice residents have the background they need to 
function in the operational arena, one of my major concerns 
has been that they be taught what they need to know to func- 
tion in a triage area. As you all know, when the Navy goes to 
war we dentists operate in close coordination with the physi- 
cian and the team that cares for people who are injured in 
battle. Our job concerns triage. I want our residents to learn 
about shock, hemorrhage, and other such problems to enable 
them to fully support you physicians in the performance of 
your assignments. Admiral Arentzen, we welcome the oppor- 
tunity to work fully and more closely with our medical col- 
leagues. 

RADM M. Conder, NC, USN: Nurse Corps recruiting is 
very good today. We are having no problems getting high- 
quality applicants. Our problem is authorized billets. To be 
certain that we are using our nurses effectively, we are look- 
ing very carefully at the number of nurses who will be placed 
in the practitioner programs. We have recently suspended the 
Ob/Gyn Nurse Practitioner Program, and we are looking at 
the other programs to determine how many more nurses, if 
any, we can put into these groups. I think nurse practitioners 
have done a fine job. I think the Navy Medical Department 
uses them well. But I do not believe I can afford many more. 

VADM Arentzen: I don't know whether all of you have met 
the new head of the Medical Service Corps, but he is CAPT 
William J. Green, Jr., sitting at the end of the table. I asked 
Bill to look into getting the MSC some audiologists. We would 
like to hear some of the problems involved in doing that. 

CAPT Green: I have been in the job about three weeks, 
and I can recall at least ten specific requests for more num- 
bers from the MSC, either to do something in the MSC or 
somewhere else. We have a fixed number, and there must be 
compensation. This is the iron rule. 

We are looking into audiologists, where we have had a 
problem for the last three years. There is no question of de- 
mand and need: the question is, how is that offset with all the 
other demands and needs? I can't tell you what we are going 
to do about it yet, but I know there is a combination of needs 
in occupational safety, in research, and in the clinical areas. 
Melting them all together is going to be difficult. 

I already know a number of you, and I am available to talk 
with you about your problems. That is the way I am going to 
learn what my job is and how to do it. I extend an open invita- 
tion to everyone: if you have some problems about using MSC 
officers — not getting them, but using them — I will be happy 
to talk to you and maybe we can work something out. 



Volume 68, February 1977 



19 



RADM J.W. Cox, MC, USN: I think the most important 
aspect of the training question is to make sure there is no 
confusion in anyone's mind as to the sets of competing im- 
peratives we face. We all know the concept of the continuum 
of graduate medical education, and the basis upon which the 
Millis Commission made that recommendation. The Millis 
recommendation for disestablishing the internship as a free- 
standing entity, and the reasons behind that recommenda- 
tion, I think were sound. But that doesn't mean that the con- 
tinuum has to run consecutively week after week, month after 
month, or year after year. It is educationally sound to modify 
the continuum, to have life's experiences reinforced by fol- 
lowing a formal study period with a work period. 

This concept is emerging in our vocational schools and a 
number of our professional schools. I can recall that students 
in teachers' colleges were always sent into schools to practice, 
to sharpen their skills. We have a plan so that graduate 
medical education level one students will have a year of tradi- 
tional training and will then move into an applicable, opera- 
tional support mode to sharpen and reinforce their skills, to 
acquire competence and maturity which will be of benefit 
when they return to the formal graduate medical education 
structure. 

I can assure you that when we were developing this concept 
and defending our graduate medical education programs 
before the AMA reference committees we were asked, are 
you returning to free-standing internships? And we are on 
record as saying no. But that doesn't mean that an individual 
has to plant himself in a hospital for two, three, or four years 
without interruption in the temporal aspects of training within 
the hospital itself. He can train just as well — with the type 
commander force medical officer giving guidance and 
checking on the quality of his performance — with the operat- 
ing forces. I think that is educationally sound. 

Another thing to remember is that training which is tailored 
to meet the needs of the Navy will also meet the crying needs 
of the civilian community for those skills. 

VADM Arentzen: I think that most of you know that CDR 
Walt Godfrey heads the Hospital Corps. We know of your 
severe problems with the number and type of technicians 
needed. So let's see if he can give you a few words on that. 

CDR Godfrey: The Hospital Corps consists of 24,000 
people. We do not expect any dramatic increases and I would 
hope no dramatic drop in those numbers. I believe our biggest 
problem is one of maldistribution. This problem has come 
upon us over a number of years because of changes in distri- 
bution of other assets — physicians, nurses, and so forth. We 
are working to bring this into line. There have been great 
changes with the physicians' billets shifting, and with 
bringing bodies into line with workload and mission; we will 
follow a similar course in the Hospital Corps. 

Personnel in Hospital Corps specialties make up approxi- 
mately 53% of our members. Most of these specialties are 
centered in the hospital area. Only 12,000 or 13,000 of our 
billets belong to BUMED and are under the control of the 
Surgeon General. The others belong to other major claimants 
and are theirs to do with as they please. We have to talk, 
cajole, do anything we can to get them to change to meet our 
system. These two areas trade back and forth because of sea 
duty, Fleet Marine Force duty, etc. With the expansion in the 
specialty areas, it is quite difficult to fill requirements. 
Additionally, we require many, many general duty corpsmen. 
We require corpsmen for the Fleet Marine Force ships, 
squadrons, etc. 



Most of the youngsters that we bring in leave us in the first 
four years. We hope to hold about 25%. In August 1976 we 
had a 14% reenlistment rate in first-term hospital corpsmen. 
This is not unique to the enlisted members of the Medical 
Department. This is happening throughout the Navy. We 
don't know quite what it means yet, but it is also happening in 
the Army and Air Force. The GI Bill has gone, and the 
economy is perking up. We are going to have more and more 
turnover. There is a task force now at work to see what can be 
done about this problem. 

If I can leave you with any one single thought, it is the utili- 
zation of the corpsmen that you have. You must recognize 
that there are not any additional corpsmen coming down the 
line, so you must make do with the people you have and not 
start new functions without stopping old functions. 

When 1 was in the field myself, many times I helped start a 
program with the idea in mind that once it got going BUMED 
would give us the assets we needed. There are people in this 
room that I have helped do that. We can't do it anymore. If 
you are going to start a new program you have got to have the 
assets to do it. If we increase specialties in neurology for ex- 
ample, we must necessarily take them from somebody else. 
There is nothing new coming down the line. 

One other thing, and this is just philosophy: your hospital 
corpsmen, particularly your young ones, are not professionals 
in this field. They are in the Navy for whatever reasons they 
have. They are in their specialty because it "looked good" to 
them. In the operating room, for example, there are two pro- 
fessionals: the doctor and the nurse. The corpsman is there 
because that specialty "looked good" to him. Three out of 
four of them are going to leave the Navy and medicine. 
Recognize this fact when you deal with them. We must try to 
reenlist these people, but the chances are very slim. 

VADM Arentzen: We will open now to any questions you 
have that have not been covered. 

Q: / want to disagree a little with what Admiral Rupnik said 
about training for contingency. I think that a well-trained 
physician knows how to care for patients — whether the 
problem is fractures, burns, or whatever. If we have spe- 
cific guidance from the line as to what contingency they 
are planning to undertake, we can train for that. I think 
that if a person is well trained and well qualified, he can 
handle the contingencies. 
RADM Rupnik: My only concern is that I recognize a de- 
emphasis in the surgical specialties. And that is all I am 
saying. I think that if we have to go to war it will be the 
surgeons and orthopedists who will be called on to take care 
of the injured. 

We are going to have to have a lot of people trained to take 
care of burned patients. We are going to have to have a lot of 
people trained in plastic surgery. We are probably going to 
have to have a lot of people trained in tropical medicine. 
These are my concerns now. 

Q: I have several questions for CDR Godfrey. You mentioned 
forgetting any idea of implementing new programs that 
require new people trained in new technical skills. What 
about those of us who have valid clinical programs where 
the people trained in the technical skills needed to support 
them don 't even exist? An excellent example of this is the 
newly developing field of noninvasive diagnostic tech- 
niques. And finally, now that we have stopped training 
EKG technicians, what are we going to do? 



U.S. Navy Medicine 



CDR Godfrey: Relative to new programs, I believe what I 
said is that if we start a new function, we must cease other 
functions. We simply cannot stretch. We don't have all those 
people to put in new functions if we are going to continue the 
old ones. It is simply a matter of time, dollars, and people, 
We certainly need new programs and we need to go into new 
areas; but when we do so we have to find other programs we 
can stop. We must set priorities. It is just that simple. 

Now about EKG technicians. The fact is that an awful lot of 
our corpsmen in many, many areas are required to know how 
to use an EKG. If they can be trained on the spot, we would 
hope that there would always be someone available that could 
use the equipment. In the emergency room, I believe all 
corpsmen assigned must know how to use EKG equipment. 
So should corpsmen in the Internal Medicine Department. I 
think all corpsmen should know how to use it, and be trained 
in how to use it. That was the prime reason for taking away 
the specialty. There was no need to limit training to any one 
group of individuals; rather we decided to spread the training 
out and let everyone learn. 

RADM Cox: I think perhaps I can elaborate. It goes beyond 
electrocardiographic technicians. It goes into ultrasound and 
other so-called specialties that emerge primarily around a 
technique; this is what causes multiple traditional disciplines. 
There is more and more recognition that fragmentation has 
resulted where disciplines are constructed on the basis of a 
given technique rather than on a system of scientific and 
technical fact. That is not a viable operation. The electrocar- 
diographic technician was a dead-end procedure in the Navy 
and it is a dead-end procedure in the civilian community. 



They have tried to get the American College of Cardiology to 
recognize them as technologists, and they fill their proposals 
with a bunch of irrelevant material to study to gain technolo- 
gist status and have accreditation procedures. But it is a tech- 
nique, not a discipline. 

Cardiopulmonary training on a tri-service basis has gone on 
for a good many years. We have the proper training program 
for a broad-based cardiopulmonary technician who, in the 
future, can narrow his specialty interest as the need de- 
mands. We are training to our own authorized requirements. 
The schools are not saturated and if it were necessary to 
expand that training because of a validated future manpower 
requirement of any service, we could do so. We are not 
training to capacity in the CP schools. 

Participant: 1 would like to thank the Director of Clinical 
Services Committee for the inclusion of the three-month 
operational tour in their deliberations. I believe I speak for 
junior medical officers in underscoring the importance of this. 
Support of the three-month concept will be interpreted by this 
group as evidence that the SAC participants have their needs 
in mind. I think that is a very important consideration. 

Participant: I have developed an increasing awareness of a 
critical weakness in the Medical Department's position. One 
of the main causes of our difficulties is the problem of obtain- 
ing the necessary resources to continue providing what we 
consider is proper medical support in the Navy. I believe that 
weakness to be our failure to develop and articulate a proper 
philosophy of the role of military medical support in the Navy 
and how that role may be properly implemented. 

In the education of a naval officer, including medical 





Clockwise from bottom left: CAPT Bishop; CAPT 
Dully; CDR Godfrey with RADM Kaufman 
(standing); CAPT Bailey; CAPT Green 



Volume 68, February 1977 





i 

1 



officers, I am unaware of any course in instruction which 
articulates the proper role of military medicine. I believe that 
proper medical support for the military may be defined as that 
medical support which is essential to victory. The support 
may be subdivided and categorized as a direct management 
of battle casualties in relation to health preservation, which is 
essential to the continuing efficient operation of the Navy. 

We must also consider the effect that medical support — 
particularly support of the families of active-duty military 
personnel— has on morale. We must realize the political im- 
portance of medical support to any military service. I need 
only cite the excellent medical support given to the military 
services in Vietnam; had it not been for the medical support, 
there is no doubt in my mind that the casualties-to-killed ratio 
would have been considerably different. The effect of this on 
the morale of the people of the United States and the military 
services, and the political implications of these statistics, 
would have been considerable — and would have altered the 
course of the war. 

There is a need to develop a proper philosophy on the role 
of military medical support, and to articulate that role in the 
form of position papers, books, and instructional courses. I 
therefore wish to make a specific proposal. After the develop- 
ment and articulation of the proper role of military medical 
support, however that may be arrived at, I propose that a new 
course be developed, to.be part of the curriculum of all naval 
officers, including medical officers entering the Navy. These 
courses should be incorporated into the Naval Academy and 
Naval ROTC programs. These courses should outline the 
proper philosophy of the role of military medical support, and 
should disseminate to people who are about to become naval 
officers information about the organization of the Medical 
Department, medical care, and a general idea of how medical 
care is provided in the civilian community. Also included 
should be a description of what we consider to be proper 
medical support for the military, and how its organization 
might differ from the general provision of medical care. 

VADM Arentzen: I don't think we could close the meeting 
without some words from our Deputy Surgeon General, 
RADM Paul Kaufman. 

RADM Kaufman: It is refreshing for me to hear what I 
have heard in this meeting and that is the approach back to 
Navy. If you listened to the Vice Chief of Naval Operations, he 
emphasized not once but several times a statement that some 
of us may take issue with. He said we are first naval officers. I 
think it didn't take him more than two sentences into his talk 
to get that out. 

As a follow-on to that, some of you have heard about the 
Naval Health Care Review Committee. I had a very sensitive 
role to play as chairman of that Committee. It was supposed 
to reflect the opinions of the line. The report is very compre- 
hensive, and includes four volumes. The last one is classified, 
but basically it says, hey, doc, how about getting into the 
Navy, finding out what it is like in the field? It emphasizes the 
point that we should first see what is out in the blue-water 
Navy and after that put it all together as a doctor, and that 
includes the doctor of dentistry as well as the doctor of medi- 
cine. I heard here that you have been ahead of us and have 
felt this change. So I applaud you for your efforts and certain- 
ly I will also support their continuation. I think Dr. Cox is to be 
congratulated, and I want to congratulate each and every one 
of you. 

VADM Arentzen: When I first came, Mr. McCullen, who 
is assistant secretary of the Navy for manpower, said to me, 

22 



"See if you can get the Medical Department back into the 
Navy. See if you can't get the line to realize that you are part 
of the team." The same thing was told to me by VADM 
Watkins, Chief of the Bureau of Naval Personnel. This we are 
going to try hard to do. 

I would like to remind you that we have one Medical De- 
partment dedicated to total patient care. Now, I don't 
consider that we have a separate branch of operational medi- 
cine. Everything we do, everything our hospitals do, is in 
support of the fleet, in my opinion. Just because some of you 
aren't sitting on a ship doesn't mean that you are not sup- 
porting the fleet. 

During my four years I am going to try to get this idea 
across. We will train, we will try to make it more exciting for 
those who have always been in a hospital environment. I don't 
expect those who are out in operational medicine to keep 
complaining that they are not getting support or that they are 
second class. If they think they are second class, they have 
got to make themselves first class by becoming more profes- 
sionally competent. They must keep up with things. 

As you probably know, one of the first things I did was to 
start out with our interns, at the GME-1 level. They must 
have some operational training before they finish. I am 
certain that our operational officers are going to rotate back 
into our hospitals, not just for residency but for tours of duty. 
They are to maintain their professional competency in 
medicine and they will then have a chance for a permanent 
change of station and a chance to command our hospitals. 

I emphasize that what we have is military medicine: it is not 
operational medicine and hospital medicine; it is not opera- 
tional medicine versus hospital medicine; it is not the haves 
and the have nots. 

1 would like to remind you that I am doing the same thing 
here that I did at my commands. I have an open door for any 
of you. My telephone is available for any of you when you 
have a problem. I would like you to go back to your com- 
mands, talk up the good things you have heard. Try to make 
the young doctor realize that military medicine can be very 
exciting. We do have lots of challenges from the line side, 
from the Office of Management and Budget, and so forth. 
They are asking us to do more than our best with less and 
less. 

I appreciate all the advice you have given us here and all 
the work you have done. I assure you that the gentlemen and 
the lady sitting up here will do their best to support every one 
of you out in the field where the action and the fun is. 

RADM Cox: I want to express, on behalf of the entire as- 
sembly, our most profound thanks to the real workhorses who 
organized this conference: CAPT Joe Cassells, CDR Brian 
McAlary, and their staffs. 

1 will leave you with one thought. We have an action- 
oriented and problem-solving mental set. In the words of 
Professor Akoff from the Wharton School of Business and 
Finance in Philadelphia, there is no such thing as a problem. 
There is a system of problems which he calls a mess, and 
what we call a problem is a mini-mess. Therefore, what you 
have done during this past week is precisely what I requested 
that you do in my welcoming remarks. You have exchanged 
information, not opinions. The presentations today identify 
the interrelationship of the mess. Having recognized the 
impact of each item on the other, we can now get about the 
job of a systems approach to a satisfactory accommodation to 
the mess, in the words of Akoff. 

My congratulations to you and my most humble thanks. 

U.S. Navy Medicine 



BUMED SITREP 



DOD HEALTH COUNCIL ... A Depart- 
ment of Defense Health Council has 
been established, chaired by the Assist- 
ant Secretary of Defense (Health Af- 
fairs), and including as members the 
Surgeons General of the three military 
departments and representatives of the 
Joint Chiefs of Staff and the Uniformed 
Services University of the Health Sci- 
ences. 

The Council will provide a central 
entity to coordinate the planning, pro- 
gramming and evaluation of DOD 
health care operations, including 
CHAMPUS, within the continental U.S. 
Under the terms of its charter, the 
Council will evaluate resource require- 
ments, oversee operations of regional 
health programs, and recommend 
health service policies to the Secretary 
of Defense. The Council will also imple- 
ment a CHAMPUS consumer appeal 
system. 

CHARGES INCREASED . . . Charges 
have been increased for medical care 
provided in overseas Navy medical facil- 
ities to civilian employees of the United 
States and their dependents. Foreign 
nationals (and their dependents) em- 
ployed by the U.S. will now be charged 
$168.00 per day for inpatient care, and 
$20.00 for each outpatient treatment, 
examination, or consultation. U.S. citi- 
zens employed by the U.S. overseas will 
also be charged $20.00 for each outpa- 
tient visit. Local union contracts or 
agreements which include old rates will 
be honored until such contracts expire. 
(These changes were published in BU- 
MED Notice 6320 of 1 Jan 1977.) 

PHYSICIAN STAFFING ... A method 
for developing staffing targets (STAFF- 
TAR) for Navy physicians by specialty 
has been successfully tested on the spe- 
cialty of orthopedics, including physical 
therapy. The test was carried out in con- 
junction with the Shore Requirements, 
Standards, and Manpower Planning 
System (SHORSTAMPS). The new 
method — which emphasizes using Navy 
board-certified specialists as consult- 
ants — will be used over the next 2Vi 
years to develop staffing criteria for all 
basic medical and surgical specialties. 

It is expected that staffing standards 
will be developed for three to five spe- 
cialties every nine months. Standards 
for general surgery, anesthesiology, 



and urology are now being developed. 
Other areas to be examined are internal 
medicine, family practice, pediatrics, 
psychiatry, pathology, radiology, oph- 
thalmology, otorhinolaryngology, ob- 
stetrics and gynecology, medical admin- 
istration, nursing, and military medical 
specialties. 

A final report of the orthopedic/ 
physical therapy results will be pub- 
lished later this year. 

AEROMEDICAL SAFETY . . . Opera- 
tional and administrative problems en- 
countered by AMSO teams, and ap- 
proaches to accident prevention and in- 
vestigation were discussed at the first 
Navywide meeting of Aeromedical Safe- 
ty Operations (AMSO) officers, held 30 
November to 1 December in Norfolk, 
Va. Attendees considered proposed 
future staffing of AMSO teams; how to 
improve communications between 
AMSO teams, BUMED and the Naval 
Safety Center; medical support to Navy 
Search And Rescue (SAR) efforts; and 
how to upgrade training in the use of 
survival and life support equipment. A 
draft of a proposed BUMED instruction 
to establish the Navy AMSO Program 
was reviewed at the meeting. 

RESIDENTS PICKED ... Of 27 flight 
surgeons who applied for Navy resi- 
dency training for FY77, 22 (81.5%) 
were chosen. The flight surgeon com- 



munity did well in all specialties, re- 
flecting a positive response to the Sur- 
geon General's direction that applica- 
tions from operationally assigned medi- 
cal officers be considered first. 

Here is a breakdown of flight surgeon 
acceptance by specialty: 

Specialty Applied Approved 

Aerospace medicine 7 6 

Family practice 2 2 

Internal medicine 1 1 
Obstetrics/ 

Gynecology 2 2 

Ophthalmology 3 3 

Orthopedics 1 1 

Otolaryngology 1 

Pediatrics 2 1 

Surgery A 2 

Psychiatry 1 1 

Radiology 2 2 
Physical medicine 

and rehabilitation 1 1 



Total 27 



22 



FLEET POOL EXTENDED ... The 

Chief of Naval Operations has approved 
extending the single manager system 
for medical officers of the fleet (fleet 
pool) until 30 Sept 1977. The approval 
stipulated that no more than two medi- 
cal officers will divide the assignment 
for any forward deployment. For more 
information, contact BUMED Codes 5 
and 31. 




LIAISON . . . Staff members of Naval Regional Medical Center Long Beach, 
Calif., held their quarterly staff medical conference in the USS Constellation 
(CV-64) last November to get a better understanding of living and working con- 
ditions aboard ship. It was all part of the fleet medical /dental liaison program 
designed to ensure quality patient care in support of the fleet. 



Volume 68, February 1977 



23 



Clinical Notes 



Medical Support in Antarctica During 



Operation Deep Freeze 

LCDR David B. Moyer, MC, USNR 



When the Antarctic Development 
Squadron Six (VXE-6) undertook 
Operation Deep Freeze 1976, an 
important objective was the the re- 
covery of two aircraft damaged on 
takeoff during the previous year's 
operation. In the 1975 effort an in- 
ternational group from the U.S., 
France, Australia, and the Soviet 
Union had established a field camp 
in Antarctica to investigate the 
thickest ice known to exist: Dome 
"Charlie," one of three ice domes 
on the high plateau of East Antarc- 
tica. While flying supplies to the In- 
ternational Antarctic Glaciologic 
Project at its Dome Charlie camp, 
two large, ski-equipped LC-130 air- 
craft belonging to VXE-6 crashed 
600 miles west of McMurdo Station. 

The technical and logistical prob- 
lems of recovering these aircraft 
were obvious; less obvious but also 
of paramount importance were 
medical problems encountered in 
the exceedingly hostile Antarctic 
environment, with its extremely low 
ambient temperatures even in mid- 
summer and its high altitude of 
10,560 feet. Because of unusually 
low barometric pressure and conse- 
quent partial pressure of oxygen, 
there is as little oxygen at 10,560 
feet in Antarctica as at sites 11,800 
feet above sea level in other parts of 
the world. 

On 31 Oct 1975, VXE-6 landed the 
first aircraft of Operation Deep 



LCDR Moyer is a flight surgeon assigned 
to Antarctic Development Squadron Six, FPO 
San Francisco 96601. 



Freeze 1976 at Dome Charlie, 
bringing 15 people to set up camp. 
For the previous three days, the 
group had stayed at South Pole Sta- 
tion {elevation 9,100 feet) to adapt 
physiologically, or acclimatize, to 
the high altitude. 

The workload was heavy during 
the first week. Temperatures 
ranged from a high of -35 °F. to a 
low of -69°F. Meals consisted of 
heated C rations, and appetites 
soon declined as lack of variety 
made the food increasingly unpalat- 
able. On 4 Nov 1975, while the 
group worked, another LC-130 was 
damaged on takeoff; three planes 
now awaited repair and salvage on 
the ice cap. 

In this first group of workers, four 
men suffered superficial frostbite 
on their hands, face or ears, but re- 
covered fully without treatment or 
sequelae. No altitude-related medi- 
cal problems were seen by the 
squadron flight surgeon or the 



corpsman who accompanied the 
men. 

The camp was evacuated on 17 
Nov 1975, then reoccupied from 7 
Dec 1975 to 19 Jan 1976 by 30 to 55 
men assigned to the second part of 
the operation, Dome Charlie IV. 
These men concentrated on repair- 
ing the downed planes and eventu- 
ally flew out two of the damaged air- 
craft. Living conditions by now 
were much improved — the group 
had a galley, hot showers and other 
amenities, and temperatures were 
milder, from -10°F. to -35°F., in the 
Antarctic midsummer. Clear weath- 
er with relatively little wind was the 
rule. 

There were no injuries or other 
major medical problems, and only 
one case of frostbite: a New Zealand 
survival expert sustained superficial 
frostbite with blistering on his ears 
after skiing cross country. All newly 
arriving personnel were required to 
acclimatize at Amundsen-Scott 



TABLE I. Medical Problems During Operation Deep Freeze 1976 

(N = 48) 



Symptoms 


None 


Mild 


Moderate 


Severe 


Shortness of breath while exercising 


12% 


72% 


16% 




Lightheadedness or dizziness 


56% 


28% 


16% 




Headache 


44% 


52% 


4% 




Numbness or tingling of fingers or 










other body areas 


68% 


20% 


12% 




Difficulty sleeping 


40% 


44% 


12% 


4% 


General fatigue 


56% 


44% 






Loss of appetite 


80% 


12% 


8% 




Nausea 


90% 


10% 






Vomiting 


98% 


2% 






More urination than usual 




8% 


8% 




Less urination than usual 




8% 


4% 





24 



U.S. Navy Medicine 







*A 







This snow house was built during Operation Deep Freeze 
survival training. 




During Operation Deep Freeze, LC-130 Hercules aircraft like 
this brought supplies and equipment to Dome Charlie. 



A Navy man melts snow on a Coleman stove to get fresh water 
during Operation Deep Freeze. 



South Pole Station for 72 hours be- 
fore proceeding to Dome Charlie; 
about half of these men developed 
mild symptoms of acute mountain 
sickness, such as headache, fatigue, 
and sleep disturbances, during their 
first days at South Pole Station. 

Everyone who arrived at Dome 
Charlie after Christmas Day filled 
out a questionnaire designed to 
identify the incidence of medical 
symptoms (Table I). No control 
group went directly from sea level 
at McMurdo Station to Dome Char- 
lie, and no unacclimatized control 
group is planned for the future; we 
would expect to see more medical 
problems in a group that had not 
acclimatized at South Pole Station. 

We made no attempt to compare 
the symptoms listed in Table I with 
the symptoms of acute mountain 

Volume 68, February 1977 



sickness or hypoxia secondary to 
low partial pressure at this altitude. 
For instance, severe sleep disturb- 
ances could have been the result of 
the stress of the new environment, 
uncomfortable quarters, continuous 
daylight, or other factors rather 
than the result of acute mountain 
sickness. To treat sleep disturb- 
ances, 10 mg of diazepan was dis- 
tributed, to be taken orally at bed- 
time. Great care was taken to alert 
the men to the more serious mani- 
festations of mountain sickness, 
especially high altitude pulmonary 
edema, but there were no cases of 
lung congestion. 

In summary, medical problems 
encountered at Dome Charlie were 
minor, and acute mountain sickness 
was ameliorated by an acclimatiza- 
tion period at South Pole Station. 

To get around in Antarctica you 
sometimes need a rope ladder. 




Independent Duty 

The Influence of High-Risk 
Groups on the Incidence 
of Gonorrhea 

CDR Lee J. Melton III, MC, USN 



As an independent duty corpsman, you undoubtedly 
have a general idea of how frequently you care for vari- 
ous specific medical complaints. But have you ever 
thought about the other side of the issue: Who are the 
patients you see most often? Do you see one patient 
over and over for the same condition? Does another pa- 
tient seem to fall victim to an endless variety of dis- 
orders? 

It is easy to observe that no disease affects everyone 
to the same degree. Even with the common cold you 
can find some people who seem to be practically im- 
mune, while others suffer from the illness repeatedly. 
What may be less obvious is that whole groups of 
people may contract a given disease far more often than 
do other groups. 

This paper will deal with the idea of such "high-risk' ' 
subpopulations in the Navy and Marine Corps. I will 
illustrate the principle with one disease, gonorrhea, 
and point out how the concept of a high-risk population 
can be useful in preventing other illnesses as well as in 
caring for patients. 

There may be many reasons for one particular sub- 
group to have a higher disease rate than the rest of a 
population. Individual biological variation, for example, 
might explain why some recruits develop clinical 
meningococcal meningitis while thousands of their 
mates are only asymptomatically infected as naso- 
pharyngeal carriers. Still other diseases may depend on 
the conditions under which a group of people lives or 
works. It is not unlikely that Marines on maneuvers in 
the Arctic will have a greater incidence of frostbite than 
other Marines, or that the engine-room crew will suffer 
more than other shipboard personnel from the adverse 
effects of heat. 

When a particular part of a population suffers dis- 
proportionately from a certain disease, we usually find 
that the members of the subgroup have common char- 
acteristics which put them at risk. Some of these char- 
acteristics have been identified. Smokers, for example, 

CDR Melton is head of the Epidemiology Section, Occupational and 
Preventive Medicine Division, Bureau of Medicine and Surgery, 2300 
E St. N.W., Washington. D.C. 20372. 



26 



have more lung cancer than do non smokers, and 
chronic alcohol abusers suffer an unusually high 
incidence of cirrhosis of the liver. Unfortunately, the 
important factors are not always clear. Sometimes, as 
in the case of ischemic heart disease, the characteristics 
can only be summarized vaguely as "lifestyle." 

Other groups have been identified that are predis- 
posed to not one, but a whole spectrum of diseases. 
One such group is often referred to as "risk takers." 
Most of us recognize that taking chances is a normal 
part of adolescence, the time when one explores his 
own limits and the limits of his environment. However, 
when carried to extremes or maintained into later life, 
risk-taking behavior can have many adverse effects. It 
has been found, for example, that risk takers are dis- 
proportionately involved in traffic accidents (i), 
smoking <2), drug abuse (3), and cases of venereal dis- 
ease (4). While the motivation for these misadventures 
is not completely understood, peer pressure and alcohol 
use seem to be prominent in provoking such behavior. 

Risk takers are an especially important group among 
Navy and Marine Corps personnel (5,6, 7). As might be 
expected, venereal disease is one of their characteristic 
problems. Not only does the sexual behavior of risk 
takers increase their chances of acquiring venereal dis- 
ease, but they probably also ignore the effective protec- 
tive measures that are available. One result: the 
sexually transmitted disease most commonly reported 
among active- duty members is gonorrhea (8). 

Characteristics of the group at high risk for 
gonorrhea have recently been illuminated in two 
studies of the crews of Navy ships deployed to the 
Western Pacific. The first study was carried out on an 
aircraft carrier by members of the Navy Medical De- 
partment and the U.S. Public Health Service. Prelimi- 
nary results from this study were presented at an 
American Public Health Association meeting held in 
October 1975 (9); some of the data are given in Table I. 

While not shown in Table I, the relative risk of ac- 
quiring gonorrhea was greater for blacks than for 
whites. On the other hand, because of their greater 
numbers in the crew, whites accounted for almost 70% 
of the cases. In Table I, only the results for white crew- 
members are shown, because their risk characteristics 
were more clearly defined. 

The data in Table I identify the high-risk group re- 
sponsible for most of the gonorrhea cases as young, 
unmarried, white males with less than a high-school 
education. Members of the high-risk group were in 
rates E-l to E-4, had served less than one year in the 
Navy, and were on their first cruise. Of particular inter- 
est with regard to risk taking was the observation that 
nearly 60% of the crewmembers in this study had never 
used a prophylactic while in the Navy; another 34% 
"seldom" or only "sometimes" used one. 

The second study was conducted by personnel from 
the Naval Health Research Center, San Diego, Calif., 
aboard a Navy destroyer also deployed to the Western 

U.S. Navy Medicine 



TABLE I. Predictors of Gonorrhea Among White 
Crewmembers {Navy/Public Health Service study} 



Characteristic 


Predictors of Risk* 


Age 


20 years or less > more than 20 years 


Education 


Less than 12 years > 12 years > more 
than 12 years 


Marital status 


Not married > married 


Pay grade 


Enlisted > officer 

E-1 to E-4 > E-5 to E-9 


Years of service 


Less than 1 year > 1 year > 2 to 9 years 
> 10 years 


Number of cruises 


First cruise > second cruise > third (or 
more) cruise 



*Crewmambers with the first predictor on each line had a greater 
(>l incidence of gonorrhea than crewmembers with the second 
predictor. 



Pacific (10). As shown in Table II, the second study 
confirmed the importance of age, race, education, 
marital status, pay grade, and years of service as pre- 
dictors of gonorrhea. This study also identified addi- 
tional relevant factors: poor performance marks, lower 
General Classification Test scores, and a record of dis- 
ciplinary actions during the cruise. 

Of course, not everyone with these characteristics 
contracts gonorrhea. Nor is gonorrhea seen exclusively 
in this high-risk group. The importance of the two 
studies is this: These characteristics, when considered 
together, identify apart of our Navy population that has 
an especially high risk of acquiring a venereal disease. 

This information is especially important to independ- 
ent duty corpsmen. You should suspect sexually trans- 
mitted disease when you diagnose conditions in mem- 
bers of the high-risk population. The data also suggest 
that you should aggressively work up vague genitouri- 
nary complaints when they occur in high-risk patients. 

The indirect importance of this knowledge may be 
even greater. In daily living, we evaluate most things 

TABLE II. Predictors of Gonorrhea 
(Naval Health Research Center study) 



Characteristic 



Predictors of Risk* 



Age 

Race 

Education 

Marital status 

Pay grade 

Years of service 

Performance marks 

General Classification 

Test score 

Disciplinary record 



Less than 20 years > 20 years or more 

Black > white 

Less than 12 years > 12 years or more 

Single > married 

E-1 to E-3 > E-4 to E-9 

Less than 1 year > 1 year or more 

3.4 or less > 3.6 to 3.8 > 4.0 

55 or less > 56 or more 

One or more disciplinary actions > no 
disciplinary actions 



"Crewmembers with the first predictor on each line had a greater 
(>) incidence of gonorrhea than crewmembers with the second 
predictor. 



on the basis of their familiar attributes. A new album by 
a favorite musical group, for example, is eagerly 
awaited solely on the strength of the group's familiar 
characteristics. The same phenomenon works in medi- 
cine: your expectations about the course of an illness or 
the outcome of therapy are often derived from the clini- 
cal picture you form from your past observations. Your 
talent for predicting the impact of a patient's disease 
characteristics can be profitably applied to anticipating 
the health effects of his personal characteristics. 

Thus, if you know that your patient is a young, un- 
married, white male who did not graduate from high 
school and who has been in the service less than one 
year, you also know he is peculiarly susceptible to cer- 
tain disorders. If he has a recent history of disciplinary 
trouble or is recovering from a minor motorcycle acci- 
dent, you might with some confidence think of him as 
belonging to the subgroup of adolescent risk takers. As 
I pointed out earlier, members of this group are heavily 
involved in medical and disciplinary problems. The 
identification of one condition, such as venereal dis- 
ease, may then permit you to predict that another be- 
havior, such as drug abuse, is likely to occur, and to 
orient your disease prevention efforts accordingly. This 
idea can be stated in more human terms: an under- 
standing of such relationships can help you to better 
interpret your patient's needs and concerns. 

Gonorrhea is not the only disease that selectively 
affects one or another group — most diseases do! Try to 
evaluate your patients on the basis of the groups they 
belong to, and to identify characteristics that place 
group members at an increased risk of illness. In this 
way, you may be able to increase your efficiency and 
improve your effectiveness in diagnosing and treating 
the problems of the people who come to you for help. 

REFERENCES 

1 . Schuman SH, et al: Young male drivers. JAMA 200:1026-1030, 
1967. 

2. Tamerin JS: Recent increase in adolescent cigarette smoking. 
Arch Gen Psychiatry 28:116-119, 1973. 

3. Crumpton E, Brill NQ: Personality factors associated with fre- 
quency of marijuana use. California Medicine 115:11-15, 1971. 

4. Stark-Romanus V: Social and behavioral aspects of venereal 
disease. Br J Vener Dis 49:163-166, 1973. 

5. Gunderson EKE, et al: The epidemiology of illness in naval 
environments. Milit Med 135:453-458, 1970. 

6. Biersner RJ, Cameron BJ: Betting reference and personality 
characteristics of Navy divers. Aerospace Medicine 41:1289-1291, 
1970. 

7. Levine JB, et al: Attitudes and accidents aboard an aircraft 
carrier. Aviat Space Environ Med 47(l):82-85, 1976. 

8. Melton LJ: Comparative incidences of gonorrhea and non- 
gonococcal urethritis in the United States Navy. Am J Epidemiol 104: 
535-542, 1976. 

9. Jones OG, et al: "Personal characteristics associated with the 
prospective risk of acquiring gonorrhea and nongonococcal urethri- 
tis." Read before the American Public Health Association annual 
meeting, Chicago, 11!., October 1975. 

10. Levine JB, et al: Social aspects of venereal disease aboard a 
U.S. Navy destroyer. J Am Vener Dis Assoc 3{l):35-39, 1976. 



Volume 68, February 1977 



27 



Notes & Announcements 



FLIGHT SURGEON BILLETS OPEN 

With fewer flight surgeons on active duty involving 
flying, many interesting and challenging billets have 
become available. Flight surgeons approaching a re- 
lease from active duty or rotation date may ask for a 
change of duty if they agree to remain at least one year 
at a new duty station within the continental U.S., or for 
the required tour length overseas. 

Reserve flight surgeons who have received release 
from active duty orders may be eligible for transfer to a 
vacant billet of their choice if they agree to extend their 
period of active duty. 

Flight surgeon billets are now open or will soon be 
available at: 

California: COMNAVSURFPAC, and the Aeromedi- 
cal Safety Operations Office of Environmental and Pre- 
ventive Medicine Unit #5, San Diego; HS-10, NAS 
North Island; Branch Clinic, El Centro; VF-126 and 
CVW-2, Miramar; Branch Clinic and Third Marine Air- 
craft Wing, MCAS El Toro; Naval Hospital, VA-127, 
andCVW-11, Lemoore; VP-19, VP-40, and VP-46, NAS 
Moffett Field. 

District of Columbia: Branch Clinic, NAF Andrews 
Air Force Base; Armed Forces Institute of Pathology. 

England: U.S. Naval Activities, United Kingdom, 
London, England. 

Florida: Naval Aerospace Medical Institute, Pensa- 
cola; Naval Regional Medical Center and HS-15, NAS 
Jacksonville; HT-18, NAS Whiting Field; CVW-1, Cecil 
Field. 

Guam: VQ-1, Agana. 

Hawaii: Naval Regional Medical Clinic, Pearl Har- 
bor; VP-1, NAS Barbers Point. 

Illinois: NRMC Great Lakes. 

Japan: Branch Clinic, MCAS Iwakuni. 

Louisiana: Naval Aerospace Medical Research 
' Laboratory Detachment, Michoud. 

Maine: Branch Clinic and VP-10, NAS Brunswick. 

Maryland: VX-1, Patuxent River. 

Morocco: Branch Hospital, U.S. Naval Training Com- 
mand, Kenitra. 

North Carolina: MAG-26 and MAG-29, New River, 
Jacksonville; Second Marine Aircraft Wing and MAG- 
32, Cherry Point. 

Okinawa: Fleet Activities, Kadena; First Marine Air- 
craft Wing. 

Pennsylvania: Naval Air Development Center, War- 
minster. 

South Carolina: Branch Clinic, MCAS Beaufort. 

Texas: Training Wing 3, Chase Field; Training Wing 
4, Corpus Christi; Branch Clinic, NAS Kingsville. 

Virginia: Naval Hospital, Quantico; Branch Clinic, 
NAS Oceana; Naval Safety Center, Environmental and 
Preventive Medicine Unit #2 Aeromedical Safety 



Operations Office, Branch Clinic, and VRF-31, NAS 
Norfolk. 

For details about any billet, contact CAPT W.W. 
Simmons, MC, USN, Bureau of Medicine and Surgery 
(Code 511), Washington, D.C. 20372. Phone (Area code 
202) 254-4361 or Autovon 294-4361. 



FINANCIAL AND SUPPLY MANAGEMENT 
TRAINING ANNOUNCED 

The Bureau of Medicine and Surgery has established 
a new training program to prepare qualified Medical 
Service Corps officers for entry level positions in 
Medical Department financial and supply manage- 
ment. The 16-week curriculum of lectures and work- 
shops will be offered at the Naval School of Health Care 
Administration, Bethesda, Md. 

The first class, to convene 31 May 1977, will include 
15 officers now stationed in the Washington, D.C, 
area. Resources are limited for transferring students to 
the training site during this fiscal year. 

A BUMED notice announcing eligibility require- 
ments for future classes and application procedures will 
be issued this spring. Students will be selected for the 
training by the Medical Service Corps Training 
Advisory Board. 



DENTAL CONTINUING EDUCATION 
COURSES SET FOR APRIL 

The following dental continuing education courses 
will be offered in April 1977: 

National Naval Dental Center, Bethesda, Md. 
Oral diagnosis and 

dental radiology 18-20 April 1977 

Periodontics 25-27 April 1977 

Eleventh Naval District, San Diego, Calif. 



Complete dentures 



18-20 April 1977 



U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D. C. 

Oral diagnosis and therapeutics 18-21 April 1977 

Armed Forces Institute of Pathology, Walter Reed 
Army Medical Center, Washington, D.C. 

Advanced forensic pathology 18-22 April 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. Applications for other dental continuing 
education courses should be submitted to: Command- 



28 



U.S. Navy Medicine 



ing Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

NEW RULES TO PURCHASE FIREARMS 

The Bureau of Alcohol, Tobacco and Firearms, De- 
partment of the Treasury, has ruled that members of 
the Armed Forces who commute to their duty stations 
across state lines may purchase a firearm in the state in 
which they are on active duty as well as in their state of 
residency. Previously, the active-duty station was con- 
sidered as the only state in which a military member 
could legally purchase firearms. 

When military bases are located near borders with 
other states — such as in the Washington, D.C., area — 
military personnel who purchase firearms may now 
transport these arms between the state where they 
work and the state where they live. 

For the purposes of federal firearms laws (U.S. Code, 
Title 18, Chapter 44), a member of the Armed Forces is 
considered a resident of the state in which his or her 
permanent duty station is located. If a member of the 
Armed Forces commutes daily from his residence in 
one state to his duty station in another state, he would 
be considered a resident of both states under the new 
ruling, and can purchase firearms in either state. 

NEW CLINIC OPENS AT NAS MEMPHIS 

A new Naval Medical and Dental Clinic was dedi- 
cated 6 Dec 1976 at Naval Air Station, Memphis, Tenn., 
with Surgeon General VADM Willard P. Arentzen 
(MC) officiating. Included in the $3.5 million structure 
are a pharmacy, laboratory, blood donor center, X-ray 
and physical therapy facilities, administrative offices, 
environmental and occupational health services, exam- 
ining rooms for military sick call and outpatient treat- 
ment, 29 dental operatories, four oral hygiene treat- 
ment rooms, and a dental prosthetic laboratory. The 
building covers 57,000 square feet: 34,100 square feet 
for medical areas and 22,900 square feet for dental 
spaces. Construction began in July 1975. 




New facility for NAS Memphis 

Volume 68, February 1977 



IMPORTANT READING MATERIAL 

Enlisted members eligible for retirement or transfer 
to the Fleet Reserve should read the following instruc- 
tions before making a final decision: BUPERS Instruc- 
tion 1750. IF, with change 1, Subj: Survivor Benefit 
Plan; and BUPERS Instruction 7220.2F with change 1, 
Subj: Retired pay computation. 

Recent changes to these instructions may influence 
your planning. Don't make a decision that could penal- 
ize you for life. Check with your personnel office: they 
have the latest instructions and can answer any 
questions. 



AWARDS AND HONORS 

Legion of Merit 

RADM W.H. Hagerman, Jr., DC, USN (Retired) 

RADM G.D. Selfridge, DC, USN (Retired) 

Meritorious Service Medal 
CAPT G.B. Crossmire, DC, USN 
CAPT H.D. Tow, Jr., DC, USN 

Navy Commendation Medal 
CAPT J.H. Charles, Jr., DC, USN 
CAPT J.D. Enoch, DC, USN 
CAPT E.J. Heinkel, Jr., DC, USN 
CAPT J.B. Holmes, DC, USN 
CAPT H.J. Keene, DC, USN 
CAPT D.E. Parry, DC, USN (Retired) 

AMERICAN BOARD CERTIFICATIONS 

American Board of Endodontics* 
CAPT Joseph H. Burke, DC, USN 

American Board of Oral Medicine* 
CDR Paul T. McDavid, DC, USN 
LCDR James T. Mellonig, DC, USN 

American Board of Oral Surgery* 
CDR Gerald B. Branham, DC, USN 

American Board of Otolaryngology 
LCDR Mark V. Connelly, MC, USNR 

American Board of Prosthodontics* 
CAPT Harry E. Semler, Jr., DC, USN 
CDR Richard A. Hesby, DC, USN 
CDR Donald L. Mitchell, DC, USN 
CDR Don R. Morris, DC, USN 

American Board of Psychiatry and Neurology 
LCDR Thomas G. Carlton, MC, USN 
LCDR Tom H. Pepper, MC, USNR 
LCDR Harold W. Ward, Jr., MC, USNR 

♦Boards recognized by the American Dental Association 



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